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

43

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

tmcleod@atsu.edu

480-219-6035

www.atpbrn.org