Professor Patrick Bernard Academic Director & Program Director (Culture & Communication )
Professor and Director, Athle
Transcript of Professor and Director, Athle
TamaraValovichMcLeod,PhD,ATC,FNATA
ProfessorandDirector,Athle<cTrainingPrograms
ResearchProfessor,SchoolofOsteopathicMedicine
inArizona
• Nofinancialbenefitrelatedtothispresenta<on
1. Discusscurrentrecommenda<onsfor
returninganindividualto
ac<vity
2. Differen<atebetweenconcussiontreatmentand
returntoplay
3. Describeac<veapproachestoconcussionmanagement
Pre-Injury Concussion-Education Parent, athlete Coach, ATC Emergency Dept Primary Care Physician Other Medical Specialist School Personnel (School RN, Psycholologist)
Knowledge and Preparation of All is the Foundation
On-field evaluation AT/MD
Athlete Concussion Suspected
Preseason BL Testing
No
Injury Monitoring
Early Identification
Return To Play (RTP)
Evidence of concussion?
Decision
SlideCourtesyofGerryGioia,PhD
Yes
Withhold from Play / Refer
Post-Injury
ClinicalEvalua4on
(24-72hours)
Neuropsychological&
BalanceTes<ng
Symptoms
Comparisonto“BL”
Management/Treatment
Medical
Sports
Academic
HomeNo
GradualExer<onal
RTPProtocol
(ATC)
Yes
Stage1
Recovery?
(atrest)
Ini<ateRTP?
No
Yes
Stage1
Recovery7?
Ini<ateRTP?
Stage2
Recovery?
(w/exer<on)
RTP?
Yes
RTPProgressionNo
SlideCourtesyofGerryGioia,PhD
REST PhysicalRest
Cogni<veRest
DaysPost-
injury
1 2 3 4 5 6 7
Mentalstatus
Postural
stability
Neuro-
cogni<on
Symptoms
• Onaverageathletesrequired7daystofullyrecovera^erconcussion(McCreaetal,JAMA2003)
• Recommendbeingasymptoma<cfor7daysbeforereturning,ifnotusingadjunct
assessments
• Progressionthatbeginswhenasymptoma4c
– NoS&Satrest– ReturntoBLonadjuncttests– Fullreturntoschool
• Considerthefollowing:– Athlete’sprevioushistoryofconcussion– Typeofsport(contactvsnon-contact)– Age– Availabilityofexperiencedpersonnel
• Observe&monitorathleteduringrecovery
Guskiewicz,JAthlTrain.2004
McCroryetal,2009
~24hoursbetweeneachstage
“there is little empirical evidence for the optimal degree and duration of physical rest needed to promote recovery or the best timing and approach for returning to full physical activity.“
https://iom.nationalacademies.org/~/media/Files/Report%20Files/2013/Concussions/concussions-RB.pdf
RestandReturn-to-Ac4vityFollowingSport-
RelatedConcussion:
ASystema4cReviewoftheLiterature
ValovichMcLeod,Lewis,Whelihan,WelchBacon,JAthlTrain.Inpress.
1. How often is cognitive and physical rest, including academic adjustments, utilized by health care providers in managing sport-related concussion?
2. In patients sustaining a concussion, does the use of physical and cognitive rest reduce the severity and duration of concussion-related impairments?
3. How compliant are healthcare providers in following current return-to-activity guidelines?
4. How effective are the graded return-to-activity protocols in improving patient outcomes following concussion?
Study Key Results
Arbogast, 2013 62% of physicians described awareness of CR as part of management; only 2.4% described CR in detail
11% of charts reviewed included written CR recommendations Carson, 2014 Worsening of symptoms in 44.7% of patients following premature RTL
Patients with prior history of concussion required more rest days before being cleared
Grubenhoff , 2015 Patients with PPCS missed 50% more school days than patients with no PPCS
36% of PPCS patients received AA, while 53% of no PPCS patients received AA
There was an association between follow-up visits and receiving AA (RR=2.2; 95% CI = 1.4-3.5)
Olympia, 2015 58% of SN are responsible for guiding students’ graduated academic re-entry process
Upchurch, 2014 CR was not recommended to any patient prior to 2008
CR was only recommended to 12% of patients by 2012
Weber, 2015 59.4% of student-athletes with concussion under SN care received AA, yet only 27.7% of
SN always or almost always recommend AA following sport-related concussion Wilkins, 2013 Instructions for RTT increased from 24% prestandardization to 98% poststandardization
Williams, 2015 41% of student-athletes with concussion under AT care received AA
Zemek, 2015 CR recommendations were limited; 40% of physicians did not recommend school absence, 30% did not recommend schoolwork reduction, 35% did not recommend limiting screen time
Valovich McLeod, Lewis, Whelihan, Welch Bacon, J Athl Train. In press.
3studiesshowingtoomuchac<vitydelayedrecovery=worseoutcomes
2studiesshowrestimprovesoutcomes
4studiesfoundnoassocia<onbetweenrestandoutcomes
1RCTfoundstrictrestresultedinalongerrecovery
Valovich McLeod, Lewis, Whelihan, Welch Bacon, J Athl Train. In press.
Noschoolorexerciseac<vity
Schoolac<vityonly
Schoolac<vityandlightac<vityathome
Schoolandsportsprac<ce
SchoolandsportsgamesMajerske,JAT,2008
• Nostudyfoundfullcompliancewithusingallthreerecommendedareasofconcussion-assessmentforreturn-to-play
– Symptoms,cogni<ve,balance
• Significantvariabilityamongguidelineusebyphysicians
– ClinicalexamcitedmostforRTAclearance
• LackofcompliancewithNCAAguidelines
• InadequateEDdischargeinstruc<onsregardingac<vityrestric<ons
Valovich McLeod, Lewis, Whelihan, Welch Bacon, J Athl Train. In press.
• Nostudiesspecificallyevaluatedtheeffec<venessofgradedRTAprogressionsin
improvingpa<entoutcomes
– 4studiesevaluatedaspectsofZurichstatement
• Zurichguidelines+BCTTmayprovideauseful
paradigmformakingsafeRTAdecisions(Darling,2014)
• UseofaSFWPdidnotimproveclinicaloutcomes
ordecreasetheriskofasame-seasonrepeat
concussion(McCrea,2009)
Valovich McLeod, Lewis, Whelihan, Welch Bacon, J Athl Train. In press.
RestandReturn-to-Ac4vityFollowing
Sport-RelatedConcussion:
ASystema4cReviewoftheLiterature
ValovichMcLeod,Lewis,Whelihan,WelchBacon,JAthlTrain.Inpress.
• Physicalandcogni<verestisunderu<lizedbyhealthcareproviders(StrengthofRecommenda<on=B)
• Moderatephysicalandcogni<verestmayfacilitaterecovery
duringtheini<aldaysa^erconcussion(Strengthof
Recommenda<on=B)
• Significantvariabilityintheuseofassessmenttoolsand
compliancewithrecommendedreturn-to-ac<vityguidelines
exists(StrengthofRecommenda<on=B)
• Thereislilleevidencetosupporttheeffec<venessofthegradedreturn-to-ac<vityprogression(Strengthof
Recommenda<on=D)
• “Rest”– Avoidanceofexacerba<ngac<vi<es
• Noneedtoshutdownareasthatdonotexacerbatesymptoms
– Abletotoleratelightaerobicexercisewithoutincreasingsymptoms?
– Abletoreadwithoutincreasingsymptoms?
– Abletoalendschoolwithoutincreasingsymptoms?
Treatment
Interven<onthatoccursbetweeninjuryandRTP
Mayincludeinterven<onsdonea^erRTP
ReturntoPlay
Progressionfrommedicalclearancetoreturntosportandfull,unrestrictedplay
Profiles
Subtypes
Dysfunc<ons
Disorders
Trajectories CollinsMWetal.,KneeSurgSportsTraumatolArthrosc2014
Mood/Anxiety
Nutri<on
SleepAcademic
Adjustments
Ves<bularTherapy
OculomotorRehabilita<on
Exercise Cervicogenic/Migraine
• Addresssleepissuesfirst– Systemsregardingarousal,alertness,alen<onandsleeparevulnerablea^erTBI(Ponsford,2012)
– Perceivedsleepdisturbancerelatedtogreatersymptomburdenandlowerneurocogni<vescores(Kostyun,2014)
• Goodsleephygiene– Aimforsimilarsleep/wake<meseachday
– Quiet,darkenvironment
– Avoidvisuals<mula<onfromelectronics
• Limitedevidencetosupportspecificnutrients
orproducts
• Suggesteddiet– Properhydra<on– Fishoil(DHA,EPA-DHA)– Avoidalcohol– Adequatecomplexcarbohydrates
– An<-inflammatorydiet
Spigt,2012;Bailes,2014;Gomez-Pinilla,2011
• Concussioncanresultinanxiety,depression,emo<onaldisturbances(Ponsford,2012;Hutchison,2009;Mainwaring,2004;Kontos,2012)
• Treatment
– Referraltopsychologist,psychiatrist,cogni<verehab– Cogni<veBehaviorInterven<on(Hodgson,2005)– Moodstabilizingmedica<ons
– Structuredenvironment(Collins,2014)
• Understandstressofremovingfromsocial(sport)
• Allowsome<mewithteammates
• Ac<vetreatmentsmayreducestress
Cervicogenic • Hemicranial pain referred
to the head by bony of soft tissue structures of the neck (Biondi, 2005)
• Treatment (Page, 2011)
– Postural correction – Manual therapy – Modalities – Exercise therapy – Breathing patterns
Migraine • Pre-existing condition
may be exacerbated • Migraine presentation can
occur after concussion • Can be caused by related
vestibular dysfunction • Treatment
– Medications – Vestibular rehabilitation
• 79%ofathle<ctrainersinhighschoolshavepersonallyencounteredasitua<onwherea
studentathletehasexperiencedadecreasein
schoolandacademicperformanceasadirect
resultofasymptoma<cconcussion
• ~44%ofconcussionsresultedinsomeformof
academicaccommoda<ons
Williams,JAthlTrain,2015
TemporaryAcademic
Adjustments504Plans
IndividualizedEduca<onPlans
(IEP)
No
ac<vity
Full
ac<vity
Asleepor
comatose
Normal
school
Goal:limitcogni<veac<vitytoalevelthatis
tolerableanddoesnotexacerbatesymptoms
hlp://issuu.com/healthone/docs/reap_oct21
Improvedcogni<ve
func<ona^erTBI
Symptomresolu<on
Moodimprovement
Improvedneuroplas<city,
cor<calconnec<vity&ac<va<on
Improvedregula<onofcerebralblood
flow
ExerciseasanInterven4on
Crane,2012,Majerske2008,Gomez-Pinella,2011;Maerlender,2015;Ahlskog,2011;
Colcombe,2004;Lautenschlager,2008
• Closelymonitoredrehabilita<oninpost-acute
phaseimprovedrecovery<meinadolescents
whowereslowtorecover(Gagnon,BrainInj,2009)
• Controlledsub-symptomthresholdaerobic
exerciseimprovedrecoveryinathleteswithPCS(Leddy,CJSM,2010,2011)
• Testtodetermineexercisetolerance– Helpstoestablishphysiologicalrecovery– Readinesstoreturntoac<vity
• ModifiedBalkeProtocol– RPE,HR,BP,symptomsassessedeach2minutes
– Testisstoppedwithincreasedsymptoms
– >3pointsfrompre-testres<ngsymptomscore
• Goodintra-raterreliabilityandsufficienttest-retestreliability(Leddy,2011)
• Recoveryinhighschoolathletes(Darling,2014)– Allathletesreturnedtosportwithoutsymptomexacerba<onorrecurrentsymptoms
– 48%hadoneormoreCNTsub-scoresbelowaverage
– BCTTbeTerpredictedreadinesstobeginRTPprotocol
• Assistswithdifferen<aldiagnosis(Leddy,2013)– Pa<entswithconcussionstopatsubmaximallevel
– Ifabletoexercisetoexhaus<onwithoutreplica<ngsymptomsthensymptomsnotduetophysiologic
concussion
– Cervicalinjury– Ves<bular/oculardysfunc<on– Post-trauma<cheadacheormigraine
• Assistwithexercisetreatment(Leddy,2016)
– Aerobicexercise20min/day@80%thresholdHR
– 5-6daysperweek– Terminateifsymptomsappearora^er20minutes
Treatment
Supervised
Documented
ProgressedMul<faceted
Planned
• Type of exercise • Duration • RPE • HR • BP • Symptoms
• Initially do not stimulate visual field, vestibular
• Progress to add stimuli
• Avoid stimulating brain activities that are correlated to symptoms
• Aerobic • Coordination • Visualization • Motivation • Education
AtypicalRecovery
– Notbacktobaselineonbalanceassessmentby10dayspost-concussion
– Impaireddynamicvisualacuitytests
– Dizziness– Mo<onprovokeddizziness
– Nausea– Blurredvisionwithheadmovement
– Mo<onsensi<vity
KeviAmes,PT,DPT
• Symptoms– Ver<go(especiallywhenlyinginbed)– Dizziness/imbalance
• Noimprovementoveroneweekorispersistentbeyondtwoweeks
• Balanceimpairments– StrongRomberg(a^eroneweek)
– BESS• ↑BLa^er1wkor>10errorsperset,>30totala^er1wk
• +DixHallpike– +/-improvementorresolu<onwithEpleymaneuver
• Pa<entsgenerallyliketheac<venatureofpar<cipa<ngintheirrecovery
JavierCardenas,MD
Interven<on
• Gazestabiliza<on(X1)• Standingbalance• Walkingwithbalancechallenges
• Canilithreposi<oning
Outcomes
• ↓Dizzinessra<ng
• ↑Ac<vi<es-specificbalanceconfidencescale
• ↓DHI
• ↑Dynamicgaitindex
• ↑Func<onalgaitassessment
• ↓TUG
• ↑SOT(allcondi<ons)
Alsalaheen,JNPT,2010
Sta<cHead&TargetSta<cHead,
DynamicTargetDynamicHead,Sta<cTarget
DynamicHead,DynamicTarget
42
Con<nueincreasingdemandassymptomsdecreasewitheach
newdemand.
CourtesyofBridgeDWallacePTPresentaFon2016
Si~ng Standing UnstableSurfaces Moving
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Con<nueincreasingdemandassymptomsdecreasewitheach
newdemand.BridgeDWallacePTPresentaFon2016
IsolatedSkills
Integra<onw/otherSkills
StableBackgrounds
BusierBackgrounds
Unpredictable
44
Con<nueincreasingdemandassymptomsdecreasewitheachnew
demand.BridgeDWallacePT-PresentaFon2016
• Evaluation – VOMS – King-Devick – Referral to neuro-optometrist or ophthalmologist
• Treatment – Oculomotor retraining / rehabilitation
• Prevention – Pre-season vision training – Exploratory study out of University of Cincinnati
shows decrease in concussion rate (9.2 vs. 1.4 concussion/100 player seasons) after preseason vision training (Clark, 2015)
Systema<cmethodtoevaluateoculomotor
func<on
– Ages9-40– Abnormalfindingsorprovoca<onofsymptoms
mayindicatedysfunc<onandresultinreferral
– Equipment
• Tapemeasures
• Metronome
• Targetwith14pointfont
Mucha,AJSM,2014
Smooth pursuits Horizontal Saccades Vertical Saccades
Convergence
Horizontal VOR Also complete Vertical VOR
Visual Motion Sensitivity
Advantages – Easy to administer – High correlation with
symptoms – High sensitivity: (+)
identify concussion – Assists in targeted
treatment plan
Possible Limitations – Unknown inter-tester
reliability – Relying on symptoms
can result in recall bias – Convergence only
measured test – No correlation to BESS
• May not be sensitive to dynamic vestibular function
• Patients with long term issues • Vergence-based oculomotor rehabilitation was effective in
individuals with mTBI who reported near work-related symptoms
• Overall improvement in nearly all of the critical, abnormal measures of vergence was observed both objectively and clinically (Thiagarajan, 2013)
• Athletic Trainer • Sports Medicine/Team
physician • Sport Physical
Therapist • Vestibular Therapist • Neurologist • Neurosurgeon • Neuropsychologist • Occupational Therapist • School Nurse
• Speech & Language Pathologist
• Physical Medicine & Rehabilitation physician
• Ocular Therapist • Behavior Optometrist • Psychologist • Psychiatrist Adjunct Team Members Coach, Teacher, Academic Counselor, Family
SlideCourtesyofBridgeDWallace,PT,DPT
• Musculoskeletalinjurya^erconcussion(Lynall,2015;Pietrosimone,2015)
• Decreasedperformancea^erconcussion(Kumar,
2014;Wasserman,2015)
• Monitoringanddocumen<ngsymptomsscore
a^erthepa<enthasreturned
• Con<nuewithves<bularoroculartherapy
• Eachpa<entisunique• Someclinicalpresenta<onsmayrespondwell
toac<vetreatments
• Treatmenttypeshoulddependonsymptom
presenta<on,medicalhistory,andpa<ent
goals
• Considercon<nuedtreatmenta^erreturnto
sport
www.atsuconcussion.com
480-219-6035
www.atpbrn.org