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Management and Rehabilitation of Concussion in Young Athletes

Kevin Walter, MD, FAAP andMick Collins, PT, DPT

Objectives

• Upon completion of this course you will be able to:

– Explain the epidemiology and pathophysiology of a concussion and identify factors that may put a patient at risk for prolonged recovery

– Screen, assess and ultimately classify patients with symptoms consistent with post-concussion syndrome into sub-groups in order to direct and optimize treatment.

– Discuss evidence based management and treatment for patients diagnosed with post-concussion syndrome targeting vestibular/ocular motor dysfunction, cervicogenic pain, exercise intolerance and psychological co-morbidities.

– Appreciate the role of neuropsychological assessment and cognitive behavioral therapy in the treatment of the complex concussion patient.

– Understand the evidence regarding methods to reduce the prevalence of pediatric sports related concussion.

OutlineMorning

• 8am - Introduction, overview

• Concussion definition, epidemiology, pathophysiology

• Acute assessment, advice/treatment

• Return to learn, gradual progression to full days, school accommodations

• Return to sport decisions including RTP protocol

• 9:45-10am - Break

• Neurocognitive assessment

• Role of the physical therapist

• Evaluating Concussions

Afternoon• 12pm-2pm – Lunch

• Concussion treatment and rehabilitation

• 3-3:15pm – Break

• Cognitive Behavioral Intervention• Research Updates• Concussion roundtable

• 5pm - End

Evidence Based Medicine

“Evidence based practice is the integration of (1) Clinical experience and expertise, (2) patient values,

and (3) best evidence (research) into the decision making process for patient care”

Sackett et al, 2004

Children’s Hospital of Wisconsin Comprehensive Sports Concussion

Program

• Medical Lead – Kevin Walter, MD

• Neuropsychology Lead – Jennifer Apps, PhD

• Psychology Lead – Matt Myrvik, PhD

• Rehabilitation Lead – Mick Collins, PT, DPT

• Athletic Trainer Lead – Trina Hoffman, MS

• Research Lead – Mike McCrea, PhD

Access

• Concussion Line: 414-337-8000

• CHW-Greenfield Clinic

– Psychology and Neuropsychology

• CHW-Mequon Clinic

• CHW-Delafield Clinic

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Our Team

• Physicians– Kevin Walter; Shayne Fehr; Kim Hornbeck; Patrick

Lehman

• Neuropsychologists– Jennifer Apps; Michelle Loman; Mike McCrea

• Physical Therapists– Mick Collins; Renee Hecker; Erin Meyer; Rob

Hofschulte; Erin Fifrick

• Psychologists– Matt Myrvik; currently recruiting

Research Team

• MCW Neurosciences

– Mike McCrea; Tim Meier; Lyn Nelson; et al.

• CHW-MCW Emergency Medicine

– Danny Thomas, MD

ConcussionKevin Walter, MD

Disclosure

• I have no financial relationships with any entities mentioned in this talk

• I did receive royalties on a textbook published in 2012

• I am the chair of the WIAA Sports Medicine Advisory Committee– Any statements made during today’s

presentations are my personal opinions and do not reflect the WIAA

Youth Sports

• 2012 CDC – 17% (and rising) 2 to 19y are obese

• Unstructured free play is decreasing & is being replaced by competitive league sports

– 41 million kids in organized sports (2013)

– Decreasing participation between 14 and 17

• Seefeldt et al: 25.3% of 10y play sports while 3.3% are involved at 18y

Youth Sports

• Youth sport participation increases self-esteem, body satisfaction, moral judgment and reasoning

– Better social and physical competence

– Decrease anxiety, depression, anger and cynicism

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Mechanism of Injury

• Can occur from either a direct hit to the head or an indirect hit to the body that transmits force to the head

• Loss of consciousness is not necessary for diagnosis and does not necessarily indicate a more severe injury or prolonged recovery

Image - http://en.wikipedia.org/wiki/Concussion

Definition

• Consensus statement on concussion in sport– 5th international conference, Berlin Oct 2016

• Traumatic brain injury induced by biomechanical forces with several common features to clinically define:– Direct blow to head, face, neck or elsewhere with

impulsive force transmitted to head

– Rapid onset of short-lived impairment of neurologic function that resolves spontaneously.• Some cases- signs and symptoms may evolve over minutes

to hours

Definition

– Neuropathologic changes but acute clinical signs and symptoms largely reflect a functional disturbance rather than structural injury• Standard neuroimaging is normal

– A range of clinical signs and symptoms that may or may no involve LOC.

– Resolution of clinical and cognitive features typically follows a sequential course• Some cases may be prolonged

• Cannot be explained by drug, alcohol, medication or other injury/comorbidity

Pathophysiology

Epidemiology

• How do we pull numbers on something poorly defined and under-reported??

• 1.6-3.8 million recreation & sports-related head injuries yearly (CDC)

• NCAA rate - 1.7 to 3.4/10000 AE from 1988-89 to 2003-04 (Hootman 2007)

• HS rate - 1.2 to 4.9/10,000 AE from 1997-98 to 2007-08 (Lincoln 2011)

• Poor injury surveillance data in youth sports– High school RIO

• 13% of ALL HS athletic injuries in practice• 24% of ALL HS athletic injuries in competition• 1 of every 5 injuries in HS athletics

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Epidemiology

• Zhang 2016: Reviewed >8.8 million insurance company medical records for diagnosis– 43,884 concussion diagnoses

• 55% male, 32% adolescent

– 10-14y = 10.5 / 1,000 patients • 87% increase from 2007-2014

– 15-19y = 16.5 / 1,000 patients• 143% increase from 2007-2014

– 55% diagnosed in ER

• Arbogast 2016: Reviewed 8,000 cases– 81.9% through PCP– 11.7% through ER– 5.2% through specialty clinics

Epidemiology

• 2010-12 Datalys– W Lax 6.9/10,000 while M Lax 6.7/10,000

– W BB 5.6/10,000 while M BB 2.8/10,000

• Under reported – McCrea et al, 2004:– 53% of athletes did NOT report concussion

– Why?• 66% - not serious enough

• 41% - did not want to leave game

• 36% - did not know it was concussion

Longer Recovery for Adolescents?• McClincy 2006: 26% HS reported

asymptomatic but still neurocognitive deficits

• McCrea - 80% take 2 weeks to recover

• Lovell 2009: 1 of 4-5 teens with symptoms over 1 month

• Barlow 2010: 14% of teens/preteens have symptoms over 3 months

• Kerr 2016: Return to play in >30 days– Youth 16.3%– HS 19.5%– College 7%– HS = highest symptom load

reporting

• Increased risk for prolonged recovery (Gioia 2008)– ADD– Chronic HA or migraines– Learning Disorder– Sleep disorder– Seizure disorder– Psych (anxiety/depression)– Repeat concussion

• Symptoms associated with prolonged recovery???– Dizziness– Significant cognitive dysfunction– Persistent fogginess– 2016 Fehr data

What Influences Recovery?

When to Refer?

• All suspected concussions require medical evaluation & clearance

• Any concussion >10-14 days

• Any athlete with >2 concussions

• Comorbidities

• High pressure families

• History of prior prolonged or difficult recovery

Evaluation - Signs

• Loss of consciousness

• Confused / dazed

• Behavior /personality changes

• Glassy eyed

• Repeats questions

• Answers questions slowly

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Evaluation: Symptoms

Cognitive Physical Emotional Sleep

Confusion Headache Irritable Hard to fall

asleep

Disoriented Nausea/Vomit Sad Wakes at night

Amnesia Dizzy Nervous More fatigued

Distractible Fatigue Mood swings

“Foggy” Vision changes More

emotional

Slow response Photo/phono

phobia

Numbness /

tingling

High school & collegiate athletes - within 3 days of injury

# 1 Headache 71-90 %

# 2 Feeling slowed down 58 %

# 3 Difficulty concentrating 57 %

# 4 Dizziness 55-70 %

# 5 Fogginess 53 %

# 6 Fatigue 50 %

# 7 Visual Blurring/double vision 49 %

# 8 Light sensitivity 47 %

# 9 Memory dysfunction 43 %

#10 Balance problems 43%

AMNESIA (anterograde or retrograde) 30%

LOSS OF CONSCIOUSNESS (usually brief) <10%

Commonly Reported Symptoms

Evaluation – Physical Exam

• ABC’s

• Assess neck

– LOC is assumed c-spine injury

• Complete neurologic exam

• SCAT5 – orientation, memory, concentration, cognition

• Balance & coordination testing

SCAT 5

Vestibular/Oculomotor Screen (VOMS)

• Assess system responsible for integrating vision, balance & movement

• Mucha 2014 article• Saccades, smooth pursuit, convergence, VO

reflex, visual motion sensitivity• Score increased symptoms after each test

– Having baseline is ideal

• Collins 2014: correlates well with PCSS scores & increases index of suspicion for CNC

• Kontos 2015: 11% false + male, 33% false + female, 77% false + motion sickness

VOMS Scorecard

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King-Devick Test

• Time test of rapid number naming

– Allows observation of eye movements

• Smaller studies show slowing in concussed athletes

• Learning effect – Leong 2015: preseason NCAA >2s slower than post season

• Galetta 2015: Sp 90%; Sn 86% when used with BESS and SAC

KD

RTclin RTclin

• Eckner et al 2011 & 2014– NCAA

• Baseline: 193+/- 21 ms

• CNC: 219 +/-31 ms

• Correlates will with established computer RT

• MacDonald et al 2015– HS

• Baseline: poor correlation between established computerized RT & RTclin test

• No postinjury test

Balance Error Scoring System

Our best validated test??

Sensitivity 34-64%

Specificity 91%

Should be done in same footwear/playing surface

McCrea. J Int Neuropsychological Soc. 2005

McCrea. JAMA. 2003

Guskiewicz. AJSM. 2000

Barr. J Int Neuropsychological Soc. 2001

Injury Management

• When in doubt, hold them out

• They often look “normal”

• No same day return to play

• Never return with symptoms

• All concussions need follow-up care

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Injury Management

• Communicate with coaches & other HCP’s

• Recheck frequently – may worsen– Never allow athlete to be alone immediately

post-injury

• Always speak with caregiver / parents– No driving home

– No after game dance or parties

• Go home to sleep– If worried enough to consider waking – send to

ER

2016 Kerr Bad News

• 3.1% of concussions resulted in return to play in <24 hours.

0%

2%

4%

6%

8%

10%

12%

Youth High School College Total

Con

cu

ssio

ns,

%

Percentage of concussions in youth, high school, and college football with return-to-play time <24 hours, 2012 to 2014 seasons

Emergency Department?

• Comfort level– With injury, patient, parents/caregivers, follow-up

care– Environmental concerns & psychosocial issues

• LOC = c-spine immobilization• Abnormal neurologic exam• Worsening symptoms or function• Seizure activity• Repeated emesis• SEND WITH INFORMATION

Neuroimaging?• In the hours after an injury if: (CT scan <6h, but reality is

more like 48h)– Worsening symptoms

– Declining level of consciousness

– Worsening amnesia

– Progressive balance disturbance

– Focal neurologic deficits

• Worry about increased future cancer risk

• Later if: (MRI)– Lack of improvement

– Worsening symptoms

– Concern for other etiology

Neuroimaging?

• PECARN (Kupperman et al 2009) n=44,000– GCS <15 or abnl mental status

– Signs of skull fx / basilar skull fx• 14% of subjects; 4.3% risk of abnl findings

• GET CT SCAN

– Lesser findings: LOC, emesis, severe mechanism of injury, severe headache• 27.7% of subjects; 0.9% with abnl findings

• Observation v CT (worsening, MD suspicion)

– Even lesser findings 58% of subjects• No CT – just observation

What’s Coming?

• Neuroimaging

– PET

– SPECT

– (fMRI)

– DTI with Tractography

• Serum biomarkers

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How much rest?

• 88 patients through ED (11 to 22y)

– “Strict rest” for 5 days (no school, work or activity) n=45

– “Usual care” 1-2 days of rest n=43

• Keep activity & symptom diary

– Calculate energy exertion

– Record daily postconcussive symptoms

• BESS and ImPACT 3 & 10 days post injury

Thomas DG, Apps JN, et al. Pediatrics 2015

How much rest?

• Both groups reported 20% decrease in physical activity & energy expenditure

• Strict rest reported more missed school days 5 to 2

• No clinically significant difference in neurocognitive or balance outcome at days 3 & 10

• The “strict rest” group report more daily symptoms & slower symptom resolution

How much rest?

• “Cocoon therapy” appears to have a negative impact

– May cause an increase in emotional symptoms

• Optimal rest is dependent on many variables

– Initial management not determined by ED, but after a few days of rest by another capable medical provider

– Schools need return to learn plan

How much rest?

• Period of rest is often defined as “until asymptomatic” which is fraught with inconsistencies– Relying on subjective symptom reports

– Symptoms after head injury are not specific to the brain (e.g. cervical spine)

– Can be interpreted differently (strict bedrest vs relative rest from intense physical activity)

• Clear that some rest, physical and cognitive, is beneficial

• Conversely too much rest may have adverse physiological and psychological consequences

Schneider, 2017

Time

Sym

pto

ms

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

To

tal S

co

re

Day

a2605F

Peterson, et al. CJSM 2014

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Premature Exercise

• Animal data

– Uncontrolled early exercise <14 days was detrimental to recovery

– Voluntary exercise in first week impaired cognitive performance

– Forced exercise 1 month into concussion impaired recovery

• Voluntary exercise was helpful

Buffalo Concussion Treadmill Test

• Based on Balke cardiac test

• Pre-exercise symptom score

• 3.2-3.6mph at 0% incline start• Incline increases 1% at minute 2, then 1% per minute

• Steady pace until patient stops due to symptoms– HR recorded as symptom threshold

• Future exercise should stay below 80% of target HR– Reassess and increase every 1-3 weeks depending on

fitness

Leddy et al CJSM 2010

• >6 weeks (3-6 weeks)

• Subsymptom threshold exercise training program

• No activity = deconditioning

• 80% max HR 5-6d/wk

– Once per day til sx onset

– Not only did exercise not worsen patients, but it made them feel better

Pediatric Specific

• Gagnon et al 2009 & 2016

– Active rehab in kids and teens 1+ month postinjury

– Aided in recovery for all

• Current research – lower HR target for kids 60%?

Activity

• Going for walks

• Must say no contact, low risk and no resistance training

• No observation of practice

+/- watching games

• Individual activity is OK – but this may get abused with coaches/athletes/personal trainers

Return to Learning

• Halstead et al, 2013 Pediatrics

• School need a plan!

• Reduce workload

• Allow breaks

• No PE class– No music? Lunchroom?

• Adjust for visual stimulus

• Gradually increase as allowed

• Good communication between all stakeholders

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What does a Concussion Plan Include?

• Absences

• Schedule of Return to Full Attendance

• Initial Return Issues– Schedule Modifications

– Initial adjustments

• Active Recovery Issues– Longer term adjustments

– “Make up” issues

– Return to Play issues

• Long-term Recovery Issues

Initial Return Issues

• Allow rest– Planned frequent rest periods– Study hall or lunch, as well as shorter portions of classes if necessary– Regularly scheduled (not random or as needed)– Pass for the nurse’s/quiet office if symptoms arise

• Emotional/behavioral outbursts due to mental fatigue• “Double work”

– Make up work/postponed testing– Adds to stress on return and can over-stimulate too quickly

• Postpone or eliminate standardized testing– Performance will be lower– Unnecessary stress

• Modified Schedules– Gym, Shop, Band, Computer classes– Noisy environments

“Long-term” Classroom/Work Assistance

• Be flexible with adjustments

• Follow through with adjustments

– This requires vigilance and increased involvement

• Reassess on at least a weekly basis or more

• Return to learn prior to return to play

– Academic adjustments means they cannot be considered symptom free

CHW RTL

• Creating online module for educators

• Advocate for RTL protocol

– There’s one for RTP!

Home

• Good sleep

– 8-12 hours per night

– Sleep habits?

– Reduce eliminate naps

• Good diet & hydration

• School first before leisure

Home

• Screens

– Youtube + TV versus school computer

– Phone

– Video games

• Keep brain occupied

• Social life & major events (wedding or homecoming)

– Have “escape plan”

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Medications?

• No pharmacologic treatment has been shown to speed recovery

– Medications can be used to treat symptoms of concussion

• Supplements have no research supporting benefits

• Off treating medications prior to RTP

• NSAID and ASA should be avoided in first 48-72h

– Platelet dysfunction

Medications?

• Meehan 2011

– Athlete’s symptoms have exceeded typical recovery period

– Symptoms negatively affecting the patient’s life to a degree that benefit > potential risks of medication

– Clinician is knowledgeable and experienced in assessment & management of concussion

Emotional Health

• Mood swings, irritability and increased emotionalness– Can spin out of control

• Concussion is a great “un-masker”• Cognitive-Behavioral Therapy

– McCarty 2016– 11-17y n=49, >1m symptoms– 6 months

• 13% CBT, 42% non-CBT still with high PCSS score• 72% CBT but 46% non-CBT with <50% reduction in

depression sx’s

Neuropsychological Evaluation

• Can provide guidance for school and medical interventions– Initial plan development– Monitoring or assessment of current status– Recommendations for level of continued assistance

• Need an experienced neuropsychologist– Especially when premorbid diagnosis exist

• Computerized testing– Just a tool for medical management– Be wary of “group” baselines– Expect score improvement as they age

• Kieslich et al 2002: 9-15y showed greatest changes

– Have a plan for use

Postconcussion Syndrome

• 2-3 weeks – patients worry about recovery• 5-6 weeks – alter lives due to injury• ICD-10:

– 3 or more of the following symptoms: headache, dizziness, fatigue, irritability, insomnia, concentration difficulty, or memory difficulty

• Pathophysiology or other– Somatization, mental health, chronic fatigue,

headache disorder, premorbid, vestibular, visual, cervical

– Deconditioning of athlete

PCS or Other?

• PT– Vestibular – Oculomotor

– Cervical• Cervical vertigo (mechanoreceptor dysfunction)

• Muscular

• More?

– Consider TMJ dysfunction

• CBT

• Cognitive rehabilitation

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Return to Activity Safely

• Must be asymptomatic, off meds, normal neuropsych profile, back to full, normal school for at least 24 – 48 hours

• Stop if any symptoms return – slow RTP program

• Extend RTP program under guidance of physician for prolonged symptoms, repeat injury

• STEP 1

– Cleared by physician to progress

– Light aerobic activity (15-20 mins)

• Walking, stationary biking, slow jogging

Return to Activity Safely• STEP 2

– Moderate aerobic activity (20-40 mins)• Sport specific (skate, run, etc). • NO EQUIPMENT

• STEP 3– Non-contact training drills in full equipment– May begin resistance training

• STEP 4– Must be cleared by physician– Begin contact in practice

• STEP 5 – Must be cleared by physician– Return to game play

• May KH, Marshall DL, et al. Pediatric sports specific return to play guidelines following concussion. Int J Sports PT, 2014; 9(2):242-255.– Sport-specific examples of RTP programs

Return to PlayRehabilitation Stage Functional Exercise Objective of Each Stage

0. No activity Symptom-limited physical and cognitive rest

Recovery

1. Light aerobic exercise Walking, swimming, stationary cycling at<70% max HR, no resistance training

Increase HR

2. Sport-specific exercise Skating drills, running drills, no head-impactactivity

Add movement

3. Non-contact drills Progression to more complex training drills e.g. passing in football/hockeyProgressive resistance training

Exercise, coordination,cognitive load

4. Non-contact practice Following medical clearance, participate innormal training activities

Restore confidence, assessfunctional skills by coachingstaff

5. Return to play Normal game play

McCrory 2013

Questions?

The Role of the Physical TherapistMick Collins, PT, DPT

Disclosure

• Nothing to disclose

• I have no financial relationships with any entities mentioned in this talk

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Referral to Physical Therapy

• Typically 1-6 weeks post injury. Can be months.

• Patients with ongoing symptoms:– Physical (headache, dizziness, cervical pain)

– Cognitive (memory, attention)

– Affective (depression, anxiety)

– Sleep related issues

• Typically demonstrate:– Vestibular-oculomotor impairments

– Exercise intolerance

– Difficulty with school attendance/participation

What is happening with concussion?

• Concussed patients have altered autonomic regulation– Increased sympathetic (“fight or flight”) and decreased

parasympathetic (“rest and digest”) function– Higher heart rate at rest and with physical and cognitive

stress– Cerebral blood flow and cerebral autoregulation (ability to

maintain constant cerebral blood flow with changes in blood pressure) are both disturbed

– Pulmonary ventilation (tidal volume x frequency) may be altered leading to decreased cerebral blood flow

• Prolonged symptoms may be due to persistent central/peripheral physiological changes, rather than a direct result of neuronal damage

Leddy 2007

Giza & Hovda 2001

Energy Crisis

• The brain needs increased energy (glucose) to assist with regaining the normal ionic balance within the brain

• Following the concussion there is decreased cerebral blood flow and mitochondrial dysfunction, which disrupts the normal metabolic function within the brain

Energy Supply < Energy Demand =

Acute Concussion Symptoms

Giza & Hovda 2001

Post Concussion Syndrome

• Term used to describe a constellation of nonspecific symptoms– Headache, fatigue, sleep disturbance, vertigo,

irritability, anxiety, depression, apathy, difficulty with concentration and exercise

• Linked to several possible causes that do not necessarily reflect ongoing physiological brain injury

• Challenge is to determine if prolonged symptoms reflect prolonged concussion pathophysiology or a manifestation of a secondary process

Leddy 2016

Brain or Strain?

• Study of patients with persistent symptoms for >3 weeks post head injury

• Cognitive, somatic and behavioral symptoms on PCS did not reliably discriminate between:

– Patients with physiological post concussion disorder (persisting symptoms + exercise intolerance on treadmill test)

– Patients with cervicogenic and/or vestibular-ocular post concussion disorder (persisting symptoms + normal exercise tolerance + abnormal cervical and/or vestibular-ocular exams)

Leddy 2015

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Cervical dysfunction following SRC

• Whiplash mechanisms are similar to impulsive forces described in concussive injuries

• Symptoms of concussion and whiplash-associated disorders display remarkable similarity:– Headache, neck pain, disturbance of

concentration/memory, dizziness, irritability, sleep disturbance, and fatigue described in concussion and whiplash patients

• Cervical zygapophyseal joints implicated as generators of headache and dizziness

Leslie, 2013

Cervical dysfunction following SRC

• Following neck trauma, there is considerable evidence to support importance of cervical dysfunction in: – Dizziness– Unsteadiness– Visual disturbances– Altered balance – Altered eye and head movement

• Evaluation of potential impairments should become part of assessment of those with traumatic neck pain– Altered cervical joint position and movement sense– Static and dynamic balance– Ocular mobility and coordination

Treleaven 2008, 2018

Concussion & Dizziness

• Between 50-80% of people experience dizziness, impaired balance and altered coordination after a concussion

• Dizziness found to be the sole on-field factor predictive of prolonged (>21 days) recovery

• Evidence of vestibular-ocular dysfunction detected in a significant proportion of children and adolescents with acute and prolonged concussion

Alsalaheen 2010, Lau 2011, Ellis 2015

The Vestibular System

• Allows eyes to remain fixed on a target while head and body move

• Sensory input from inner ear allows for adjustments in eye movements and motor control that stabilize head and body during movement

• Involves vestibular apparatus, sensory organs, and central processing and coordination in brain

• Specific areas of brain are responsible for integrating sensory information– Cerebellum, cerebral cortex, thalamus, reticular

formation, brainstem

Kontos 2017

The Vestibular System

Consists of two systems:

• Vestibulo-spinal component – regulates postural stability

• Vestibulo-ocular component – maintains visual stability during head movements

• Together play a vital role in balance, gaze stabilization, and visual and spatial orientation

Kontos 2017

Vestibulo-spinal component

• Helps to regulate postural stability– Objective balance impairments usually resolve in 3-5 days

post-concussion– Screen with:

• BESS Test • Sensory

Organization Test(SOT)

Kontos 2017

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Vestibulo-ocular component

• Integrates vision and movement of the head– 30% of patients with a

concussion report visual symptoms in the first week after injury. Symptoms may persist

– 50-80% of patients experience dizziness

– Screen with:• Vestibular Oculomotor Screen

(VOMS)

Kontos 2017

Oculomotor function

• Underlying pathophysiology of oculomotordysfunction after SRC is complex

– Occurs via versional eye movements (pursuits and saccades) and vergence movements (convergence and divergence)

– Combine with visual fixation movements (gaze holding, optokinetic responses, VOR)

– Change angle of gaze and hold visual images steady

Kontos 2017

Vestibular/OculomotorSymptoms

Kontos 2017

Vestibular symptoms Oculomotor symptoms

Dizziness Headaches

Nausea Blurred vision

Vertigo Convergence insufficiency

Blurred or unstable vision Difficulty reading

Discomfort in busy environments Diplopia

Loss of balance Difficulty tracking a moving target

Unsteady gait Asthenopia

Problems scanning for visualinformation

Vestibular/OculomotorSymptoms

• Concussion patients may not always report “dizziness”, may need to ask specific questions about symptoms:– Blurry vision, difficulty focusing, “fogginess”– Discomfort with motion

• Stairs, walking, driving

– Challenged with busy visual environments• Crowds, walking through hallways or stores, attending

practices or games

– Impaired balance especially in the dark

• Dizziness Handicap Inventory to help identify impairments

Mucha 2014

Questions?

Evaluating ConcussionsMick Collins, PT, DPT

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Subjective

• Date of injury and mechanism

• Immediate/current symptoms– Activities that increase symptoms

– Symptom patterns – time of day, frequency, severity

• Prior level of function– Academics, activity

• Past medical history– Concussion hx, orthopedic hx, migraines, cervical

pain, mental health, ADD/ADHD, learning difficulty

Subjective

• Social/living situation• School status

– Attending full or partial days– Using accommodations

• Reading/screen tolerance• Sleep hygiene

– Melatonin, valerian root?

• Mood• Diet/hydration• Prior imaging, neurocognitive testing

Education

• Take this opportunity to educate patient and family

• Lots of misconceptions, misunderstandings

• Dispel myths early, reduce fear and anxiety

• Improve rapport and patient compliance

Importance of Early Intervention and Education

• Individuals seen at one week post mTBI and provided with an information booklet reported less symptoms (particularly anxiety and sleep disturbances)

• Those who were only seen at 3 months and not provided with an information booklet reported higher levels of psychological distress

Ponsford, 2002

Concussion Knowledge

• Understanding– Symptomology

– Appropriate referral to MD, less understanding of appropriate referral to vestibular PT or manual PT

– Need for comprehensive evaluation

– Multifaceted approach to treatment

55 question survey taken by 1,272 physical therapists

• Deficits– Need for imaging

– Use of concussion severity scales

– Grading concussions (mild vs complex)

– Need for more conservative management of youth concussions

Yorke, 2016

Concussion Knowledge

• Knowledge assessment

– Most participants able to identify consequences of concussion including potentially catastrophic outcomes and future risk of injury

– Only 22% aware of difference in concussion risk between genders

– Only 34% knew concussion is a brain injury

• Concern over long term consequences

– Females, health care employees and parents expressed more concern for long term consequences

– Athletes expressed more concern about not being able to RTP

15 Coaches, 115 Athletes and 132 Parents

Nanos, 2017

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So What Do I Say?

• Force transmitted to brain that causes shearing• Results in nerve cell dysfunction and changes in blood

flow • Less energy produced within nerve, more energy used

to return nerve to normal (ATP pumps)– Results in supply/demand imbalance in affected nerves

• PT exercises targeted at adaptation/habituation strategies: Expose–Recover–Expose– Make unaffected nerves work harder to limit impact on

recovering nerves– Normalize cerebral blood flow, removal of lactic acid and

inflammatory accumulation– Sibling chore analogy

Objective

• Neuro exam

– Cranial nerves I-XII

– DTRs

• Biceps brachii C5 Brachioradialis C6 Triceps C7

– Myotomes

– Dermatomes

– Babinski, Hoffman’s

• Cervical exam– ROM/joint mobility– Trigger points– Special tests

– Cervical distraction test– Flexion rotation test– Headache differentiation

– (C0-1, C1-2, C2-3)– Spurling's test– Quadrant test– Upper limb tension test– Alar Ligament stress test– Sharp-Purser test– Anterior Shear test

– Muscle performance– Scapular endurance test– Neck flexor endurance test– Lateral lift test

Cook, 2012

Vestibular Oculomotor Screen (VOMS)Methods

• 64 patients, aged 13.9 ± 2.5, 5.5 ± 4.0 days post-SRC

• Administered PCSS and VOMS assessment:

1. Smooth pursuits

2. Horizontal and vertical saccades

3. Near point of convergence (NPC) distance

4. Horizontal vestibular ocular reflex (VOR)

5. Visual motion sensitivity (VMS)

6. *Vertical VOR added in to revision*

• Patients verbally rate changes in symptoms– Headache, dizziness, nausea and fogginess

Mucha 2014

Vestibular Oculomotor Screen (VOMS)Results

• 61% reported symptom provocation after 1 VOMS item• No control subjects reported any symptoms > 2/10 for any item• VOMS items positively correlated to PCSS total symptom score• VOR and VMS most predictive of being in concussed group• Mean NPC distance in concussed group 4cm greater than control

• NPC distance ≥ 5cm increased probability of correctly identifying concussed patients by 34%– +LR 5.8

• VOMS item score ≥ 2/10 increased probability of correctly identifying concussed patients by 46%– +LR 23.9 (smooth pursuit, vertical saccade), +LR 42.8 (VOR)

• Positive VOR, VMS, & NPC leads to a positive predictive value of 0.89 of identifying concussion

Mucha 2014

VOMS Components

• Convergence – near point

• Smooth pursuits/gaze fixation

• Saccades – horizontal

• Saccades – vertical

• VOR – horizontal

• VOR – vertical

• Visual Motion Sensitivity / VOR Cancellation

Mucha 2014

VOMS Application

• Document baseline symptoms – headache, dizziness, nausea, fogginess, blurred vision, asthenopia (eye strain)– Rate symptoms 0-10/10 (similar to NPRS)

• Positive test – eyes not moving together/symmetrically or reproduction of symptoms

• Reassess symptoms after each segment of testing

• Allow them to rest and have symptoms decrease before moving onto next segment

Mucha 2014

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Convergence

• Focus on a small target at arms length, then slowly bring it in toward nose

• Stop when two distinct images are seen or outward deviation of eye is observed –blurry vision is okay

• 3 repetitions – measure distance from nose to target

• Abnormal test is > 6 cm

• Reassess symptomsWhitney, 2016

Smooth Pursuits

• Hold fingertip 3 feet away from patient

• Patient tracks target as you move about 30° left and right (about 1.5 feet each direction) – 2 repetitions

• Should take about 2 seconds to go from left to right

• Reassess symptoms

• Repeat verticallyWhitney, 2016

Horizontal & Vertical Saccades

• Sit 3 feet from patient and hold each of your index fingertips about 3 feet apart horizontally (1.5 feet to the left/right of midline)

• Patient quickly switches gaze from one target to the other

• Reassess symptoms

• Repeat verticallyWhitney, 2016

Vestibular-Ocular Reflex (VOR)

• Stabilizes or focuses vision on a target while the head moves

• If the head rotates 10° to the right, eyes should move 10° to left to keep object focused

• Impairment results in dizziness or blurred vision when the eyes and/or head moves

• Can be impaired due to central and/or peripheral problems

Whitney, 2016

Vestibular-Ocular Reflex (VOR)

• Patient focuses on a target 3 feet away

• Rotate head horizontally while keeping the target in focus – 20° each direction, 10 cycles

• 180 beats/minute is normal – could use metronome

• Assess symptoms 10 seconds after each test

• Repeat verticallyWhitney, 2016

Visual Motion Sensitivity

• Discomfort or uneasiness created by visual stimuli

• Moving in crowds, supermarkets, busy patterns, stairs, heights

• “Heightened awareness of normal visual motion” – visual filter not working

• Known comorbidity with migraines/anxiety

Furman 2010, Mucha 2014

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Visual Motion Sensitivity

• May be referred to as VOR cancellation

• Patient holds arms outstretched, focus on thumb or another target and rotate arms left/right 80°

• 50 beats/minute for 5 cycles (10 swipes) is normal – could use metronome

• Assess symptoms

Whitney, 2016

Other Vestibular Tests

• BPPV Testing – Dix Hallpike, Horizontal Roll Test

• Cover & Uncover Tests (Tropias/Phorias)

– Look for head tilt or misalignment of eyes

• Optokinetic nystagmus

• Head Thrust Test (VOR)

• Head Shake Nystagmus Test (VOR)

– Requires Frenzel goggles

Mucha 2014

Balance Assessment

• Balance Error Scoring System (BESS) Test

– 6 segments: each lasts 20 seconds

– Eyes closed, hands on hips, no shoes

– Feet together, tandem stance, single leg stance

– May skip single leg if < 13 years old

– Test on both solid ground and on airex pad

– Non-dominant side for single leg stance, non-dominant foot behind for tandem stance

– Spot patient for safety

Riemann 1999

BESS Scoring

Errors1. Hands lifted off of iliac crest2. Opening eyes3. Step, stumble, or fall4. Moving hip into > 30 degrees abduction5. Lifting forefoot or heel6. Remaining out of test position > 5

seconds

Add one point for each error during each of the six 20-second tests

If unable to hold position for 5 seconds, score the maximum number of errors (10)

Riemann 1999

BESS Reliability

• 241 pediatric, 102 adult patients, concussion symptoms lasting longer than 10 days

• Reliability

• ICC minimally improved with omission of firm double and foam double stance

• Study demonstrates high reliability for BESS in cohort of patients with prolonged concussion symptoms

Cushman 2018

COBALT• 576 athletes, 10-25 years old• 4 conditions, 20sec trials

– C3: EC, firm, head shake (baseline)– C4: VOR cancellation, firm (baseline)– C7: EC, foam, head shake

• Feet shoulder width, 120bpm, 30 degrees each direction

– C8: VOR cancellation, foam• Feet together, 40bpm, 30 degrees each direction

• Error and sway scores collected• 7.9% had more than one error on C7

– 92.1% able to complete C7 with one error or less– >1 error, likely not ready to RTP

• 1.7% had more than one error on C8– 98.3% able to complete C7 with one error or less– >1 error, VERY likely not ready to RTP

Massingale, under revision

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Graded Exertion Testing

• Looking to assess sub-symptomatic threshold

• Can help determine treatment classification• Assists with safe exercise prescription• Balke Treadmill test (BCTT)

– 15mins, 3.3mph, progress to 15% incline increasing incline 1% every minute

– HR monitored throughout– Terminate test with symptom provocation

(increase of >3 from baseline)– Symptoms should subside with rest

• If they don’t, maybe emotional component to recovery

Leddy 2010

Safety, clinical use and outcomes

• 106 patients, mean age 15.1 years old, range 11-19 years, 141 tests total– 97.9% of treadmill tests were well tolerated (3 tests

discontinued due to LE soreness)

• 61 underwent treadmill testing to classify PCS subtype– Diagnosed 58 of 61 patients with physiological PCS, 1 with

cervicogenic PCS, 2 indeterminate

• 65 underwent treadmill testing to confirm physiological recovery– Confirmed physiological recovery in 96.9% of patients, with

successful RTP in 93.8%

• 41 with physiologic PCS underwent complete clinical follow up and treated with submaximal aerobic exercise– 90.2% clinically improved, 80.5% RTP

Cordingley, 2016

Cordingley, 2016 Cordingley, 2016

How soon is safe?• 54 patients, mean age 15 years, 4 days post injury

– 27 performed BCTT on visit 1, 27 did not– Heart rate threshold (HRt) at symptom exacerbation established– Patients recorded symptoms daily for 14 days then had follow

up BCTT– Recovery defined as return to normal symptoms and exercise

tolerance

• Days to recover and typical vs prolonged recovery not different between groups– Symptom severity scores decreased in both groups and were

similar 1 day post BCTT– Lower HRt on day 1 associated with prolonged recovery

• Use of BCTT within first week did not affect recovery– Degree of early exercise tolerance important for prognosis

Leddy, 2017

Questions?

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Concussion Treatment and

RehabilitationMick Collins, PT, DPT

Concussion Treatment

• Usually multi-faceted:– Address cervicothoracic dysfunction

• Cervicothoracic and soft tissue mobilization

• Scapular and deep cervical flexor strengthening

– Postural retraining and ergonomics

– Gaze stabilization/vestibular exercises

– Balance and proprioception

– Active rehabilitation

– Cardiovascular/aerobic activities progressing to sport specific activities

Broglio 2015, Leddy 2016, Ellis 2016, Grabowski 2016

When to start?

• 677 patients, 7-18 years old• Intervention

– Aerobic activity, coordination skill/practice, visualization, education and motivation

• All patients experienced improvement of symptoms while participating in active rehab– Patients starting at 2 or 3 weeks post injury

demonstrated lower symptom severity at f/u (2 weeks later) than those starting at 6 weeks or more

– Patients starting at 2 weeks post injury demonstrated lower symptom severity at f/u than those starting at less than 2 weeks, 4 weeks and 5 weeks

Dobney, 2017

Treatment Classification

Ellis 2015

• Physiologic• Vestibulo-ocular• Cervicogenic

Collins 2013

Treatment Classification

• Cervicogenic– Headaches, migraines, dizziness

• Vestibular/Oculomotor– VOR, saccades, convergence, motion sensitivity– Positional changes

• Physiologic– Exercise intolerance

• Emotional– Depression, anxiety, irritability, frustration, self-esteem,

confidence, fatigue

Lots of overlap between treatment groups both initially and as treatment progresses

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Cervicogenic

Pathophysiology Symptoms Physical exam findings

• Muscle trauma andinflammation• Joint dysfunction• Dysfunction of cervical spine proprioception

• Neck pain, stiffness• Decreased ROM• Occipital headaches exacerbated by movement not physical or cognitive activity• Lightheadedness and postural imbalance

• Decreased cervical lordosis and ROM• Paraspinal and sub-occipital tenderness• Impaired cervical proprioception• Positive cervical special tests• Tolerated max exertion on graded treadmill testing

Ellis 2015

Manual therapy and exercise

• Combination of manual therapy and exercise indicated for cervical treatment

• Manual therapy:– Joint mobilization/manipulation– Soft tissue mobilization, stretching– Muscle energy techniques– Dry needling if available

• Exercise– Postural strengthening (scapular stabilizers, deep

cervical flexors)

Cook, 2012

Cervical Proprioception

• Measure cervical joint position sense– Laser pointer mounted on headband– Patient seated 90cm from wall, starting

position of laser marked– Patient eyes closed performs an active

neck movement and returns to starting position

– Distance between start and finish measured

• Train cervical joint position sense– Relocate head back to natural head

posture and to predetermined positions

Treleaven, 2018

Vestibular/Oculomotor

Pathophysiology Symptoms Physical exam findings

• Dysfunction of the vestibular and oculomotor systems

• Dizziness, vertigo, nausea, light-headedness• Gait and postural instability• Blurred or double vision• Difficulty tracking objects• Motion sensitivity• Photophobia• Symptoms exacerbated by visual stimulus (reading, riding in car, screen time)

• Impairments on standardized balance and gait testing• Impaired VOR, fixation, convergence, horizontal/vertical saccades• Tolerated maximal exertion on graded treadmill testing

Ellis 2015

VOR Exercises

• Place target on wall or hold in front of you, shake head left/right or nod up/down while keeping the target focused

• Start with slow speed, few repetitions• Eventual goal

– at least 1 minute, 180 beats/minute, can use a metronome

• Progressions– Busier backgrounds/environments, VOR with

walking/running forward/backward or with balance challenges

Whitney, 2016

Convergence

• Bring target in toward nose and back out

– Pencil pushups

– Brock string

– Playing catch

• Switch focus from near target to far target within the same line of sight

Whitney, 2016

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Saccades

• Quickly switch gaze from one target to another

• Horizontal or vertical

• Can vary the distance between or the depths of the targets

• Can progress to diagonals

• Can vary background

Whitney, 2016

Eye Tracking

• Lazer pen– Follow with eyes

– Tag

• Eye maze

• Number find– Can vary patterns 1-15, 15-1, odds up/evens

down to add in cognitive dual task

• Can incorporate balance challenges for sensory integration

Whitney, 2016

Visual Motion Sensitivity

• Hold target in front of you at arms’ distance

• Rotate left/right with head/arms while keeping target focused

• Progression – core rotations, PNF patterns

Whitney, 2016

Dynamic VOR activity

• Familiar exercises with visual focus on target

– Sit-ups with ball overhead

– Russian twists with rotation

– Med ball chops on BOSU

– Step ups with overhead press

– Wall sits with rotation

– Lunges with rotation or with overhead lean

– Resisted trunk rotation

Whitney, 2016

Cervicovestibular rehabilitation

• 31 patients - 18 male, 13 female, 18-30years, diagnosed with SRC – dizziness, headache, neck pain

• Weekly sessions with a PT for 8 weeks or until medical clearance

• Control group– Postural education, ROM, cognitive and physical rest

followed by graded exertion protocol

• Intervention group– Same as control + cervical spine and vestibular rehab

• 73% of treatment group medically cleared within 8 weeks vs 7% in control group

Schneider, 2014

Physiologic

Pathophysiology Symptoms Physical exam findings

• Persistent alterations in neuronal depolarization, cell membrane permeability, mitochondrial function, cellular metabolism and cerebral blood flow

• Headache exacerbated by physical and cognitive exertion• Nausea, intermittent vomiting, photophobia,phonophobia, dizziness, fatigue, difficulty concentrating, slowed speech

• No focal neurological findings• Elevated resting HR• Graded treadmill tests are often terminated early due to symptom onset or exacerbation

Ellis 2015

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Graded exertion and Active rehabilitation

• Patients with persistent post-concussion symptoms may have impaired autonomic dysfunction and impaired cerebral auto-regulation

• Aerobic training may increase parasympathetic activity, decrease sympathetic activity and improve cerebral blood flow

• Usually start active rehab/cardio activity after patient is asymptomatic or if symptoms are lasting > 2-4 weeks

Leddy 2010, Cordingley 2016

Active Rehabilitation

• Gradually increase cardiovascular activity

• Heart rate monitored throughout

• Start at 50-60% max HR,

build to 80%+ -

subsymptomatic

threshold

• Progress low to high impact activity (stationary bike to elliptical to running)

AGE 60% 70% 80%

13 124 145 165

14 123 144 165

15 123 144 164

16 122 143 163

17 122 142 162

18 121 141 162

19 121 141 161

Leddy 2010

Sport-Specific

• Increasing impact and intensity of activity as tolerated

• Remain below symptom threshold– Intervals– Plyometrics– Circuit training– Agility and coordination– Sport-specific drills and

exercises

Gagnon 2015

Discharge and Return to Play Considerations

• No symptoms reported during ADLs including school for >1 week

• Negative VOMS• Negative cervical screen – ROM, deep flexor endurance,

cervical rotation test, trigger points• BESS within age appropriate norms• Tolerates sustained cardio >15mins at 60-70% max HR

without an increase in symptoms• Tolerates sport specific activity at 80%+ max HR without

an increase in symptoms – Short burst, high intensity, sport related movements

• Dual task? Reaction time? Y-balance?

Discharge and Return to Play Considerations

• Communicate with referring provider to ensure RTP is appropriate

• Patient must then progress through 5 step RTP protocol

Return to PlayRehabilitation Stage Functional Exercise Objective of Each Stage

1. No activity Symptom-limited physical and cognitive rest

Recovery

2. Light aerobic exercise Walking, swimming, stationary cycling at<70% max HR, no resistance training

Increase HR

3. Sport-specific exercise Skating drills, running drills, no head-impactactivity

Add movement

4. Non-contact drills Progression to more complex training drills e.g. passing in football/hockeyProgressive resistance training

Exercise, coordination,cognitive load

5. Non-contact practice Following medical clearance, participate innormal training activities

Restore confidence, assessfunctional skills by coachingstaff

6. Return to play Normal game play

McCrory 2013

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Emotional

• Emotional and psychological factors can play a role in recovery

• Pre-existing conditions can be exacerbated

• Injury can cause increased levels of anxiety, depression, sleep disturbances, decreased motivation, confidence and self esteem

• Important to refer appropriately if necessary

Team Approach

• May need to involve additional treatment team members if symptoms are not responding as expected – discuss with patient and referring physician

– Psychologist – cognitive-behavioral therapy

– Neuropsychologist – continued difficulty with focusing/concentrating/schoolwork

– Neuro-opthalmologist – persistent ocular symptoms

– Otolaryngologist (ENT) – vestibular/ear symptoms

Leddy 2016

Questions?

Signs/Symptoms of ConcussionPhysical Cognitive Emotional Sleep

• Headache• Nausea• Vomiting• Poor

balance• Visual

problems• Fatigue• Light

sensitivity• Noise

sensitivity

• Fogginess• Cognitive

slowing• Poor

concentration• Memory

concerns• Confused• Slow

processing

• Irritability• Sadness• Emotional• Nervous

• Drowsiness• Sleeping

more• Sleeping less• Difficulty

falling asleep

Psychological Symptoms?Physical Cognitive Emotional Sleep

• Headache• Nausea• Vomiting• Poor

balance• Visual

problems• Fatigue• Light

sensitivity• Noise

sensitivity

• Fogginess• Cognitive

slowing• Poor

concentration• Memory

concerns• Confused• Slow

processing

• Irritability• Sadness• Emotional• Nervous

• Drowsiness• Sleeping

more• Sleeping less• Difficulty

falling asleep

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Effects of “Other Factors”

Lishman, 1988

Psychiatric Co-morbidity

High in individuals with persistent concussion symptoms

• 2/3 meet diagnostic criteria for Axis I or II disorder

Overlapping symptoms between psychiatric and persistent concussion symptoms

• E.g., sleep difficulties (mood vs. concussion)

Serves as starting point to frame intervention for persistent concussion symptoms

Cognitive Behavior Therapy (CBT) for Persistent Concussion Symptoms

Potter et al, 2012

General CBT Model

Think

FeelDo

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Concussion CBT Model

Think

Feel (E)

Feel (P)

Do

“Feel (P)”

Symptom Self-Management

Goal: Symptom management

• Headaches

• Nausea

Education:

• Creaky house

• Gas pedal vs. brake pedal

Creaky House

Live in old creaky house…

• Night 1: Hear noises, it’s just windows and floor

• Night 2: Hear noises, it’s just windows and floor

– Wake up in morning, someone broke in!

• Night 3: Hear noises, what is it?

Sympathetic Activation

Pain Run Excited Worried

Heart Rate

RespirationRate

Blood Pressure

Parasympathetic Activation

Pain Run Excited Worried Relax

Heart Rate

RespirationRate

Blood Pressure

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Gas Pedal vs. Brake Pedal

Pain Run Excited Worried Relax

Heart Rate

RespirationRate

Blood Pressure

GAS BRAKE

Relaxation Training

Diaphragmatic Breathing

– Promotes parasympathetic response

Progressive Muscle Relaxation

– Reduces muscle tension/promotes body awareness

Guided Imagery/Visualization

– Distraction

• Most lack interoceptive awareness

• Biofeedback:– Physiological processes recorded

– Physiological information presented

– Patient attends to information and

attempts to alter process

• Heart rate

• Respiration

• Blood pressure

• Muscle tension

• Peripheral blood flow

Biofeedback

Provide signal

Process feedback

“DO”

Behavioral Interventions

Goal: Increase functioning

Problems:

• Typical recommendation is “rest” post-injury

• Perceived worsening symptoms after earlier attempts to return to previous activities

• Kinesiophobia

• Cogniphobia

• High desire to return to “normal” functioning

Behavioral RegulationTwo types of activity patterns:

1. Under-exertion: fear of pain, avoidance, deconditioning, disability

2. Over-exertion: unhealthy high levels of activity, task persistence, disability

Symptoms

Over-exertion

Under-exertion

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Dog Phobia Example

Think that every dog bites…

Avoidance

If I think that “every dog bites”…

• I will never be around a dog

• If never around a dog, will my thought ever change?

Avoidance of Symptoms

Behavioral Experiments• Goal: address belief that all activity will

result in symptom exacerbation

• Set up small experiments to prove…

Activity≠ Symptoms

Flooding

So I need to be around a dog…

• Lock me in a room with 15 dogs

• Makes me scared, which the makes dogs scared

• When dogs are scared, they are more likely to…

BITE!

Over-Exertion/Pushing Too Hard

Pacing• Goal: Address behavior resulting in

symptom exacerbation

• Work in “bursts” Activity

Rest

Activity

Rest

Sleep hygiene• Consistent bedtime and wake time

• Consistent bedtime routine

• Avoid spending non-sleep time in bed

• Avoid screen time prior to bed

• Avoid caffeine

• 20-10 rule

• Shift bedtime Sleep Symptoms

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“Think”

Cognitive InterventionsGoal: reduce maladaptive thoughts about symptoms

Problems:

• Underestimation of pre-injury symptoms (good old day bias)– Perceptions of existence, hypervigilance, differences in

responding

• Perfectionism– Concerns about failing to meet standards

– Self-evaluation even more polarized

– Self-criticism and/or procrastination maintain unmet standards

Cognitive Distortions

Identify negative beliefs:

• Black & white thinking: I can’t remember anything

• Generalization: Can’t remember that answer, so here we go again

• Mental filter: Can’t believe I got 5 wrong on test

Cognitive Distortions

Identify negative beliefs:

• Fortune telling: My memory will never come back

• Mind reading: Others do not believe my symptoms

• Catastrophizing: Due to my grades, I will never get into college

Cognitive Modification

Re-attributing problems

• Pre-morbid functioning

• Alternative influencing factors

Interpreting perceived mistakes

• Not end of world

• Behavioral experiments

What to refer for?

• Mood/anxiety concerns

• Poor compliance with physical therapy

• Poor adjustment with injury/activity limitations

• Continued focus on injury or recovery

• Unclear etiology of symptoms

• Not meeting treatment goals

• Pain management

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How to refer?

• Never say due to stress or anything “psych” related

• Focus on the need to “aid recovery” and impaired functioning (school, pain, sleep, not playing sport)

• Focuses on goal of returning to normal functioning

• Not “talk therapy”

Questions?

Legislation/Policy, Education, Protective Equipment, Retirement

Future Risk?

• HS FB players (n=438) no different from HS band members (n=140) for future Dementia (3%:1.4%); Parkinson (2.3%:3.6%); ALS (0.5%:0.7%) Savica, 2012

– NFL speed positions higher risk of Alzheimer, Parkinson, ALS than general population/non-speed Lehman 2012

• 2017, Alosco et al – (n=214 w/o other contact sports) earlier exposure to football is associated with increased odds for impairment in neuropsychiatric and executive functioning– Especially if started before 12y

– Self-report

Chronic Traumatic Encephalopathy

• Progressive neurodegenerative disease where repetitive brain trauma is felt to cause build-up of tau protein & cause irreversible damage– Memory loss, impaired judgement, mental health

disorders, impulse control problems, dementia– Found post-mortem only

• There is no proven link or pathway from youth football to CTE– Felt to be related to repetitive sub-concussive head

impacts over time (years?)– How do concussions & treatment factor in?

• Found in other contact sports, military veterans, and non-collegiate and non-professional athletes

Culture

• Destin Julian

– 16y MI HS football player being recruited for D-1

– Homecoming 2015 – helmet to helmet = seizure & hospitalized

• 2 days earlier – similar contact with symptoms

• Coach discouraged reporting to play in homecoming

– Coach called players “sissies” and “urged to shake it off” and “play through pain”

– IA, IL, NC, NY, PA – all with recent HS lawsuits

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Types of Contact

CONTACT INTENSITY

DESCRIPTION

Air 0 Players run drill unopposed without contact

Bags 1 Drill is executed against a bag, shield, or pad (soft contact surface)

Control (Wrap)

2 Drill is run at full speed until moment of contact. One player is pre-determined winner. Contact above waist. Players remain on feet.

Thud 3 Drill run at full speed until moment of contact. No pre-determined winner. Contact remains above waist. No one is taken to ground. Quick whistle ends drill.

Live Action (Full Contact)

4 Live action in game-like conditions. Only time that players are taken to ground

Improved Coaching

• Heads Up Football

– USA Football for youth tackle football (6-14y)

– Online program to educate coaches about proper tackling fundamentals and reducing head contact

– Educate coaches on creating a practice plan

• Assign a level of contact for every drill

– Follow acclimatization guidelines

USA Football

• Preseason– No more than 4 practices/wk

– Full contact no more than 30 min/day & no more than 120 min/wk

– No two-a-days

• Regular season– No more than 3 practices/wk (plus game)

– Full contact no more than 30 min/day & 90 min/wk

WIAA Football Contact Limits• Acclimatization regulations apply.

• Week 1: Only drill contact (air, bags, wrap) is allowed & is unlimited.

• Week 2: Full contact (thud and live) is limited to 75 mins per week, excluding one scrimmage. Unlimited drill contact.

• Week 3 & beyond: Full contact is limited to 60 mins per week, excluding games. Unlimited drill contact.

NFHS Guidelines• Full contact should be limited

– No more than 2-3 practices per week• Consider no more than 30 mins per day and 60-90

mins per week

• Consider eliminating full contact on consecutive days

– Preseason practice may require more full contact time than in season practices (learn fundamentals)

– Two-a-Days – only one should include full contact

– Review policies for total quarters/games per week• Participation at multiple levels increases risk

It Works!

• Early HS RIO NFHS data shows reduction in states that have implemented limitations

• Datalys Center 2012-2014 for Heads Up Football leagues compared to non-adopters

– 76% injury reduction

– 57% less likely to sustain time-loss injury (24h)

– 34% reduction of practice related concussion

– 29% reduction of game related concussion

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“Fair Play”/Sportsmanship

• Give extra points to teams in standings for less penalties– Quebec Pee Wee (11-12y)

• Fewer minor penalties, 5x less major penalties, no fights, 50% reduction in game suspensions

– Quebec Bantam (13-14y)• 30% less major penalties, 25% less game suspensions

– Minnesota Youth Hockey• Hits to head 12.4/100 games to 2/100 games• Checks from behind 23/100 games to 8.5/100 games

• Coaches that emphasize sportsmanship and good behavior can reduce illegal contact

Concussion Education

• Many articles show benefits• Cusimano 2009 (youth ice hockey)

– ¼ young athletes &parents could not name 1 symptom of concussion

– ¼ young athletes were unsure if you could play after sustaining a concussion

• Mihalik 2014– Younger athletes had lower concussion knowledge and

awareness

• Lin et al 2015– Low income and low education levels showed less

knowledge and awareness of concussion

Concussion Education

• Israel 2012 (134 HS varsity FB players)– 10% diagnosed with concussion by physician

or AT– 32% had concussion symptoms after contact

in last 2 seasons & did not report• >50% concerned about not playing

• Chrisman et al 2014 (3 years after law)– Concussion education after WA state law has

had substantial positive impact on HS soccer and FB coaches

– More limited impact on athletes and parents• FB receives more education than soccer

Concussion Education – Jan 2016 CJSM

• Compared to 2004 McCrea et al study (1999-2002 HS FB)• 784 HS FB players (2013) v 1,532 (1999-2002)• Increased reporting of suspected CNC

– 78.6% vs. 47.3%– More likely to report to coach

• Reasons for not reporting– Did not want to be pulled– Did not think it was serious enough

• Concussion law– 59.5% knew about law– 68% of concussed athletes said it made no difference in

reporting– 64% of non-concussed athletes said it made them more likely to

report

Know Your Law

• All 50 states have one

–Based on 3 main components:

• Improving education & awareness

• Immediate removal from play for suspected concussion

• No return to play without written medical clearance

–No same day RTP

Sidelined For Safety ActWisconsin Concussion Law

• All youth sports (<19y)

– Not college

• Signed coach, athlete, parent information sheet each year

• Immediate removal of athlete with suspected concussion

• Written medical clearance by appropriate healthcare provider

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Have the Laws Been Helpful?

• Gibson et al 2015 (WA state 2008-2012)

– States w/ law had 92% increase in CNC-related visits compared to states without law (75%)

• Mackenzie et al 2015

– ED visits in RI had 2.2-fold increase

– No corresponding increase in head CT

• Trojian et al 2015

– ED visits in CT had 2.6-fold increase

MCW Research

• Compared prior study of HS athletes (1999-2002) to 2013 cohort– 2002 – 47% likely to report CNC

– 2013 – increased to 71%• Only 60% aware of law

• 55% saying law made them more likely to report injury

• Laws have helped build awareness and education– Need culture change for full reporting

Protective Equipment

• 2015 Zuckerman et al – acute outcomes in helmeted v unhelmeted sports are similar

• Helmets– Excellent for reducing catastrophic head injury

• Mouthguards– Excellent for reducing dental injury

• There is no “Concussion-Proof” helmet or mouthguard– Helmets may reduce amount of impact to skull, but

there is no evidence that this has actually reduced concussion incidence

McCrory et al 2013; Daneshevar et al. 2011; Benson et al. 2009; Guskiewicz et al. 2014

Protective Equipment – McGuine et al

• 2081 HS players / 2287 player seasons

– 2012 + 2013 seasons = 134,437 exposures

• 206 players (9%) w/ 211 concussions

– No difference in helmet type (Riddell 1171; Schutt680, Xenith 436)

– No difference in helmet age or recondition status

– Custom mouthguard use 60% more likely to sustain concussion than generic mouth guard

• Only 9% of players wore custom2014 Am J Sports Med: McGuine, Hetzel, McCrea, Brooks.

Protective Equipment – McGuine et al

• Previous concussion in last 12 months 2x as likely to sustain concussion

• Competition rate 7x > practice– Contact practice 4x > non-contact

• Did not correlate with concussion risk– Player age, size, competition level– Years of tackle football experience

• Guskiewicz & Valovich McLeod 2011 – younger start in contact = more likely to have multiple concussions

• Emery et al 2010 – younger checking in hockey had 70% concussion increase than non-check leagues

2014 Am J Sports Med: McGuine, Hetzel, McCrea, Brooks.

Football Helmets – Collins et al

• Feb 2016 AJSM

• High School RIO data from 2008-9 to 2012-13

– 28% of concussions in Schutt (total of 38% wore Schutt)

– 67% of concussions in Riddell (60% total)

– No difference in sx’s & recovery

• Newer, expensive helmets not significantly better for concussion risk

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Accelerometers

• Placed in helmets or on skull to assess the force and magnitude of impact in real time

• Forbes et al 2012 – Average impact to cause concussion in HS 93.9g translational acceleration & 6505.2rad/s2 rotational acceleration– However, only 0.02% of all collisions resulted in

concussion

• Guskiewicz & Mihalik 2011 – Concussions occur at lower magnitude than originally thought– Linear acceleration and rotational acceleration are

equally likely to cause concussion

Accelerometers

• Accelerometers should NOT be used to predict injury

• Threshold is still elusive

• Not helpful for diagnosis

• Emerging data showing inaccuracy

• May be helpful as behavior modification tool

• Illustrate to athletes and coaches the location and character of hits during tackling & blocking

• Promote techniques to reduce frequency and magnitude of head impact exposure

Guskiewicz et al 2011, Forbes et al 2012; Guskiewicz et al 2014

Mouthguards

• 1964 Stenger article of 5 ND football players that had concussions prior to mouthguard & none after

– Winters now advocates for custom mouthguards

• Wisniewski & Guskiewicz 2004 - NCAA

• McGuine & Brooks 2014 – HS

– No preventive effect for concussion

• Dental and oral-facial trauma reduction

RetirementKevin Walter, MD

Odds & Ends

• HS FB players (n=438) no different from HS band members (n=140) for future Dementia (3%:1.4%); Parkinson (2.3%:3.6%); ALS (0.5%:0.7%) Savica, 2012

• NFL speed positions higher risk of Alzheimer, Parkinson, ALS than general population/non-speed Lehman 2012

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Number of Concussions

Am

ou

nt of

Bad

nes

s

Unique and Variable

• Incomplete recovery• How many overall?

– Per season: 2-3– Rapid occurrence– Prolonged recovery

• Decreasing mechanism of injury or “easy concussibility”– ApoE4 gene – worse outcomes

• Impact on life• Neuroimaging abnormalities

– Chiari, hemorrhage

• Parental or athlete anxiety

The injury of concussion is not the true problem; it is the

mismanagement of this brain injury that is the real issue.

Changing the Culture

• Chad Stover• Chris Coyne• Zack Lystedt

• Balance participation & safety• Accept rule changes (even ones that may “alter”

the game)– Evolution of sport to find balance

• Encourage responsible athletes, parents, coaches, health care professionals

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balance disorders after concussion. J Neurol Phys Ther. 2010;34(2):87–93. doi:10.1097/NPT.0b013e3181dde568.

2. Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and Emerging Rehabilitation for Concussion. Clinics in Sports Medicine. 2015;34(2):213-231. doi:10.1016/j.csm.2014.12.005.

3. Collins MW, Kontos AP, Reynolds E, Murawski CD, Fu FH. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surgery, Sports Traumatology, Arthroscopy. 2013;22(2):235-246. doi:10.1007/s00167-013-2791-6.

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11. Furman J, Balaban C, Jacob R, Marcus D. Migraine-anxiety related dizziness (MARD): a new disorder? J Neurol NeurosurgPsychiatry. 2005;76:1–8. doi:10.1136/jnnp.2004.048926.

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Buffalo; 2008. 18. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-

Related Concussion Among High School Football Players? Am J Sports Med. 2011;39(11):2311–2318. doi:10.1177/0363546511410655.

19. Leddy JJ, Baker JG, Willer B. Active Rehabilitation of Concussion and Post-concussion Syndrome. Physical Medicine and Rehabilitation Clinics of North America. 2016;27(2):437-454. doi:10.1016/j.pmr.2015.12.003.

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Thank You!

Mick Collins PT, DPT

CHW Physical Therapy

mjcollins@chw.org

Kevin Walter, MD

MCW/CHW Sports Medicine

kwalter@chw.org

Matt Myrvik, PhD

MCW/CHW

mmyrvik@mcw.edu

Jen Apps, PhD

MCW/CHW

japps@chw.org

Tim Meier, PhD

MCW

tmeier@mcw.edu