• Jennifer Parent-Nichols has no conflicts to disclose.

• Concussion understanding continues to be

modified

Sciencewatch.com

“Its about the injury…and

who comes with the injury.”

McCrea, 2016

Postconcussionsyndromeawarenessuk.com

10-20%

of

patients

Non-

specific

definition

Symptoms vary

• Too much or too little rest

• Premorbid dx or family hx migraine, ADHD, mood disorder, other psychiatric disorder, LD

• Poor management of acute injury

• Untreated vestibular or cervicogenic dysfunction

• Exposure to re-injury prior to full recovery

(Morgan, 2015)

• Repetitive injuries (literature conflicts concerning what this number might be)

• Younger patients

• Being female

• Type of hit or speed of hit does NOT appear to have an impact on length of recovery

Theconcussionblog.com

Gymprofessor.com

Dailymail.co.uk

New Research: HR at which sx are first provoked,

seems to be a predictor of recovery.

• Persistent Post Concussion Sx:

•Clinical Risk Score

• Increased: female, >13 yos, hx of migraine, prior

concussion c sx>1wk, HA, sensitivity to noise, fatigue,

answering questions more slowly, 4+ errors on BESS

tandem stance

Injoewetrust.com.au

• Not by typical imaging

• MRI SWI, Yuh, 2012

• Longer echo times sensitive to compounds

• Can see micro hemorrhage

• Amount seems to be correlated to longer recovery time

En.wikipedia.com

Quizlet.com

•CBF, Claussen et al, J HeadTraumaRehab, 2016

• CBF is altered in acute concussion

• See ~ 1mo p concussion

• CBF is altered in PCS

• Brain is the only organ without a blood test

• Need to be able to detect elements of the neurometabolic

cascade

• Need right tool at right time

• Challenge in mTBI

• ? Astrocytes

• Glia predominate 10:1

• UCH- 1

• GFAP

Spectrumnews.org

Should Include: • Specific History

• Post-concussion Symptom Inventory

• Cervical Screening

• Neurologic Exam: Coordination/Reaction Time

• Balance

• Vision/Vestibular

• Gait and Function: FGA, 3 meter tandem gait, DGI, Dual (cognitive-motor), Sports Specific

• May send conflicting proprioceptive/visual/ vestibular info related

to balance (Brandt 2001)

• Postural screening

• PROM, AROM

• Palpation of boney landmarks and soft tissue

• Dermatomes, Myotomes

• Neck strength/Motor control: 2mm Hg x 5 2-3 sec (Schneider)

• Provocation tests

• Note: neck pain is common, especially after trauma. Look for pain

lasting longer than 7-10 day acute period.

• Cranial nerve testing

• Reflexes

• Tone

• Global Strength

• Coordination/Reaction

Healthtap.com

Telegraph.co.uk

Blog.beamery.com

SOT

• Look for a >30% decrement

in performance from the

static to dynamic measure Oandp.org

Ajot.aota.org

CTSIB BESS

• Visual vergence: normal <5cm

• Visual pursuit: is it smooth?

• Visual saccades: moving from visual target to visual

target. Is it smooth, is it well timed?

• Presence of strabismus

• Photosensitivity

www.buzzle.com

• VOR

• Stabilize visual target with head turning

• Dynamic visual acuity metronome 120 bpm (2 hz)

• 120 degrees/sec=typical ADL’s, can go up to 250 degrees/sec

• Head impulse/Head thrust

• (VOR cancellation)

• VMS: pt report

• BPPV: Roll tests/ Dix Hallpike

•Otoconia dislodged = sx vertigo

•Not typically seen in younger populations

• head shaking nystagmus

Medical-instituion.com

Ocular Function

1. Smooth Pursuits

2. Horizontal and Vertical Saccades

3. Near Point Convergence (NPC)

Vestibular Function

4. Horizontal VOR

5. Vertical VOR

6. Visual Motion Sensitivity (VMS)

Pts rate 0 (none) to 10 (severe) changes in: headache, dizziness, nausea and fogginess symptoms

• Even just a head shake with a Romberg

Youtube.com

Concussiontreatment.com

• Remove from play

• Limit cognitive and physical activity

• Encourage pt to not participate in activities that

raise risk of second injury

• Monitor sleep and mood

• All subsequent activity is pt specific, based on

sx presentation/resolution and requires

consistent monitoring/evaluation by the team.

Webmd.com

Need to choose the right treatment at the right time…

Anitabrooks.com

Always monitor and assess symptoms

• Must have objective baseline

measurements for comparison

Always education

Process is SLOW: decreased

speed, decreased reps,

decreased sensory stimulation

Use good sense: early

exercise is monitored.

Too much=bad, Too

little=bad.

Famalii.com

Bunkiechamber.net

Br J Sports Med 2014, Schneider:

intervention with PT

Rx group 10x more

likely to be returned

to sport than in the

control group.

• Melatonin

• Meds

• Biofeedback

• Sleep hygiene

• Sun exposure

• MSK!

• ROM

• TPI

• Mobs

• STM

• Dry needling

• Taping

Sportsrehabcenter.com

Cchirosw.com

123rf.com

• Oculomotor Training

• Progressive VOR training (vertical and horizontal)

• Progressive visual sensitivity training

•Can change speed, number of reps, complexity

• Pt symptoms will be the guide

Fitnessgaming.com

Binbpt.com

• Pursuit: tracking tubes

• Saccades: Suduko, crossword puzzles, increase font

size, line grids

• Convergence: Brock String

• Eye Strain/HA: apps for rest breaks, colored tints for

computer screen

• Vestibular

• Progressive accommodation

• Moving toward function. Visionhelp.wordpress.com

• Early exercise after mTBI = noted decrease in plasticity (Greisbach, 2004)

• BUT…

• Strict Rest=No benefit, sx influenced by rest (Thomas et al,

2014)

• Well timed ex =decrease in recovery time, improved sx,

and increased tolerance to ex over time. (Leddy et al, 2010,

Gagnon et al, 2015)

O-connecta.ca

• Restriction of activity NOT removal

• Sx should be manageable, not necessarily abolished

• Gagnon, et al, 2016.

• Historically: rx at 4 weeks post

• Now: data suggesting potential benefits from

beginning at 2 weeks post.

Activerehab.com

• Aerobic component: ? Use of BCTT

• 5 min warm up

• Exercise to 80% max HR 20 min/day

• Increase HR by 5 bpm every week.

• Sports Specific Activity

• Mental Imagery

• Education

• Prolonged ssx can be anxiety provoking

and isolating

• Time to sx provocation recorded

• Iverson, et al 2012.

Hub.jhu.edu

• Return to Play = Return to Risk

• Significant increase in time to recovery if 2nd

injury before 1st resolved

• Look at Sx burden

• determine where we are and where we’re going

• PRACTICAL AND LOGICAL

• Stratified care: look at degree of disability and

determine strategy

Nike.com

Blog.mioglobal.com

• Use exercise tolerance as proxy

• Brain Function is DIFFERENT in concussed individuals.

Wang Y et al., J Neurotrauma 2015 epub

Meier TB, et al.,

JAMA Neurol 2015

• Abnormally

phosphorlated/degenerates

• Seems pathogenic/different from

aging

• Makes tau sticky

• Dose dependent

• Seen with concussion

• Correlates with axonal injury

• But eventually seen all over

• Administration of antibody targeting

of cis tau seems to prevent/limit

functional deficits…in mice

Vectorchildrenshospital.org

• The better is the enemy of the good. Voltaire

• Berlin…2016

Twitter.com

References

• Alsalaheen, B. A., Mucha, A., Morris, L. O., Whitney, S. L., Furman, J. M., Camiolo-Reddy, C. E., ... & Sparto, P. J. (2010). Vestibular rehabilitation for dizziness and balance disorders after concussion. Journal of Neurologic Physical Therapy, 34(2), 87-93.Brandt, T., & Bronstein, A. M. (2001). Cervical vertigo. Journal of Neurology, Neurosurgery & Psychiatry, 71(1), 8-12.

• Clausen, M., Pendergast, D. R., Willer, B., & Leddy, J. (2016). Cerebral blood flow during treadmill exercise is a marker of physiological postconcussion syndrome in female athletes. The Journal of head trauma rehabilitation, 31(3), 215-224.

• Gagnon, I., Grilli, L., Friedman, D., Iverson, G. (2016). A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Scand J Med Sci Sports, 26(3), 299-306.

• Griesbach, G. S., Hovda, D. A., Molteni, R., Wu, A., & Gomez-Pinilla, F. (2004). Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience,125(1), 129-139.

• Iverson, G., Gagnon, I., & Greisbach, G. S. (2012). Active rehabilitation for slow-to-recover children. Mild traumatic brain injury in children and adolescents: From basic science to clinical management, 281.

• Kondo, A., Shahpasand, K., Mannix, R., Qiu, J., Moncaster, J., Chen, C.-H., Lu, K. P. (2015). cis p-tau: early driver of brain injury and tauopathy blocked by antibody. Nature, 523(7561), 431–436. http://doi.org/10.1038/nature14658

• Leddy et al. (2016). In press.

• Leddy, J., Hinds, A., Sirica, D., & Willer, B. (2016). The role of controlled exercise in concussion management. PM&R, 8(3), 91-100.

• Leddy, J. J., Kozlowski, K., Donnelly, J. P., Pendergast, D. R., Epstein, L. H., & Willer, B. (2010). A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clinical Journal of Sport Medicine, 20(1), 21-27.

• Leddy, J. J., & Willer, B. (2013). Use of graded exercise testing in concussion and return-to-activity management. Current sports medicine reports, 12(6), 370-376.

• Meier TB, Bellgowan PF, Singh R, Kuplicki R, Polanski DW, Mayer AR. Recovery of Cerebral Blood Flow Following Sports-Related Concussion. JAMA Neurol.2015;72(5):530-538.

• Mucha, A., Collins, M. W., Elbin, R. J., Furman, J. M., Troutman-Enseki, C., DeWolf, R. M., & Kontos, A. P. (2014). A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions preliminary findings. The American journal of sports medicine, 0363546514543775.

• Schneider, K. J., Meeuwisse, W. H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J., & Emery, C. A. (2014). Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British journal of sports medicine, bjsports-2013.

• Wang, Y., Nelson, L. D., LaRoche, A. A., Pfaller, A. Y., Nencka, A. S., Koch, K. M., & McCrea, M. A. (2015). Cerebral blood flow alterations in acute sport-related concussion. Journal of neurotrauma.

• Yuh, E. L., & Gean, A. D. (2012). Structural neuroimaging. Brain Injury Medicine: Principles and Practice, 194.

• Zemek, R., Barrowman, N., Freedman, S. B., Gravel, J., Gagnon, I., McGahern, C., ... & Craig, W. (2016). Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED.JAMA, 315(10), 1014-1025.

• CTSIB/SOT: clinical test of sensory integration on balance

• BOT-2: Bruininks-Oseretsky test of motor proficiency 2

• BESS: balance error scoring system

• DHI: dizziness handicap inventory

• DGI: dynamic gait index

• FGA: functional gait assessment

• 5 Times Sit to Stand/ 30 seconds sit to stand

• (Alsalaheen2010)

• Romberg/ sharpened

Romberg

• Single leg stance

• Star Test

• Line walking

• Timed up and go

• Berg Balance Scale

Buffalo Concussion Treadmill Test

• Ex to sx tolerance

• RPE>18=RECOVERED

• Push to increase sx, then back

off

• Ask pt every 60 seconds if

increase in sx or new sx= 1

point

• 3 points=stop

• ? Starting RTP from here

Buffalo.edu

Leddy, et al (2013).

• ImPACT, HeadMinder, CogSport

• Above are baseline and for comparison

• Post Concussion Symptom Inventory

• King Devik

• Rivermead Post-Concussion Symptoms

Questionnaire

Kingdevik.com

Impacttest.com