Katie Barnes Wood, PT, DPTOrthotennessee Therapy

April 28, 2018

How and Why Physical Therapy Can Help Concussions

Concussion Therapy

My BackgroundGraduate of Farragut High

School

Bachelor of Arts in Physical Education at Maryville College

Doctorate of Physical Therapy at Western Carolina University

Focus on Sport-Related Concussions

Concussion Rehab at KOCOur Care Team

Athletic Trainers

MDs

Physical Therapy

Outside Referrals

Cognitive Therapy

Speech Therapy

Psychological Counseling

Vision Care Providers

You!

Background

Concussions are a MILD TRAUMATIC BRAIN INJURY (mTBI)Variety of causes

DOES NOT REQUIRE LOSS OF CONSCIOUSNESS

DOES NOT REQUIRE A “HIT” FROM ANOTHER PLAYER!

Concussion Review

CDC estimates ~1.1 million people treated with non-fatal TBI annually in ER1

Estimated 300,000 are moderate

128 per 100,000 in US yearly

At least 75% of all TBIs reported each year are MILD2

5/10 concussions go unreported or undetected3

The Facts

4

“A physiological disruption of brain function caused by an external force”5

Damage to tissues of the brain White Matter Grey Matter Neurons/Axons

Initiates metabolic changes within the brain6

Can see metabolic changes occurring as far out as 10 days May take 30 days to return to baseline

What is happening in the brain?

PotassiumCalcium

ATP Glucose

Period of decreased

cerebral blood flow

Lactate

What does an invisible injury look like?

75-94% Headache

57% Difficulty Concentrating

52% Fatigue

51% Drowsiness

49% Dizzy

7

Predictors of Delayed Recovery

• History of Prior Concussion

• Headache• Dizziness• Slow to rise• On-field amnesia

Look

Appears dazed or stunned (such as glassy eyes)

Forgets an instruction or play

Is unsure of score or opponent

Moves clumsily or has poor balance

Answers questions slowly

Loses consciousness (even briefly)

Cannot recall events prior to or after hit or fall

Listen

Blurry

Vision

I forgot

where I’m

supposed

to be

Anxiety

Nervous

Stressed

I can’t

focus!

I just

don’t

feel

normal

My head is

killing me!

My

balance is

never this

bad!

Chronic Traumatic Encephalopathy8

Linked to repetitive head trauma

Can appear in the late 20s Seen in mood changes,

aggression, impulsivity

Symptoms worsen with age Parkinsonism, speech

changes, memory loss, confusion

Exposure <12 y.o. associated with worse outcomes

REQUIRES POST-MORTEM EXAM

Second Impact Syndrome1

Only seen in younger populations

RARE

Second concussion sustained while patient is still symptomatic from first concussion

Brain loses ability to control intracranial pressure and blood flow Brainstem herniation

Death within 2-5 minutes

More Serious Considerations

So your student has a concussion… what next?

“Any youth athlete who shows signs, symptoms and behavior consistent with a concussion shall immediately be removed from the activity or competition for evaluation by a licensed health care professional, if available, by the coach or by other designated person”9

“No youth athlete who has been removed from play due to suspected concussion shall return to practice or competition until the youth athlete is evaluated by a health care provider and receives written clearance from the health care provider for a full or graduated return to play”9

Slow Resolution or Worsening of Symptoms? Get Help!

APTA Position Statement10

“Physical therapists are part of the multidisciplinary team of licensed health care providers that provides concussion management, which includes: education and prevention to minimize risk and increase awareness

examination and evaluation to establish a diagnosis, treatment through implementation of a plan of care, monitoring of progress, and making return to participation decisions by using best available evidence and standards of care.”

There’s physical therapy for concussions?

Concussion Rehabilitation

Vestibular

All the other stuff

CervicalOcular

Who have we been seeing? (April 2017-April 2018)

46%

54%

Males vs Females

Male: Female:

0

5

10

15

20

25

10 to 12 13 to 15 16-18 19-21 22-25 >26

Ages

Subjective is KEY

Cervical Spine Vertebral Artery Test

Ligament Testing

Transverse Ligament

Alar Ligament

Movement Testing

“Does this make you dizzy?”

Strength Testing

Examining and Evaluating Concussions

Convergence - The Ability of the Eyes to Work Together

https://www.youtube.com/watch?v=_xqRESp_KUA

One of the fastest movements in the body

Creates a 3D, more accurate perception of our world

Imagine implications for activities like…Walking down the hallway at school

Driving

Reading

Looking between the board and notes in class

Playing a sport

Saccades – how accurately can you shift gaze?

Smooth Pursuit – the ability to follow a moving target

https://www.youtube.com/watch?v=gqCgzSSwPLk

Visual Motion Sensitivity Maintaining focus on a target

while the head and body are moving

Actually inhibits VOR

Imagine implications for the athlete…

Vestibulo-ocular Reflex Stabilizes images on the

retina

Keeps the world stable

Helps to interpret environment while mobile

“The world is bouncing…”

Vestibulo-ocular Reflex and Visual Motion Sensitivity

Balance Testing

Vision + Proprioception + Vestibular = Balance

Increased sway

Less reactionary response

Slowed processing with dual tasks

Avoidance of movements that cause increased symptoms

Initial Testing Varies Based on the Patient…

Evaluation is largely dictated by the

patient’s response to testing

Not uncommon for testing to take

place over several visits

This part gets a little more fun…

The examination helps determine what needs to be fixedMany times, it’s more

than one thing!

Focus may shift during treatment sessions

Once all the testing is done… what’s next?

Feeling Better!

Ocular Retraining

Vestibular Retraining

Exertion Therapy

Motion Sensitivity Exposure

Balance Training

Cognitive Tasking

What kind of “exercises” are we talking about?

Ocular Vestibular

Cervical Exertion

Concussion Therapy

Voluntary, gentle exercise = good!Neuroprotective properties following brain injury

Positive Effects on Mental Health combats depression in athletes

Having said that…Vigorous activity too early actually takes LONGER to return to play

Important to avoid any activities that could result in additional injury

Is it safe to exercise?

Research indicates that patients who start guided exercise and vestibular

rehabilitation before 6 weeks post-injury return to play FASTER!

The Other News

Concussions will continue to happen…

We need more information!

Complex nature of concussions make treatment protocols difficult to develop

NECESSITATES “community” approach to put the pieces together

The Good News

Vestibular and Ocular Rehab is supported in literature Limited studies

Exertion Protocols can guide safe return to activity

We see improvements in the clinic every day

The sooner we address needs, the faster they get better!

Does it work?

SleepAllow them to sleep at night!

Sleep schedule

Avoiding naps, caffeine

MedicationAmitryptiline

Amantadine

SSRIs

Supplements

Magnesium

Melatonin

Cognitive/Behavioral Therapy

Light/Noise SensitivityCreate a Good Environment

“Blue” setting on electronics when necessary

Academic modificationsHomebound/Partial Days

Extra time for assignments

Audiotaped lectures

Management of the Concussed

Create approachable environment to report symptoms

Keep them engaged with team!

Parent Education

Support with Home Exercise Program

Management of the Concussed

Must Identify ON FIELDOn-field amnesia

Headache

Dizziness

Graded Return to PlayCollaboration between

coaches, Ats

Must challenge performance BEFORE full return to sport

Red Flags

Thank you!

Questions & Discussion

1. Bey T, Ostick, B. Second Impact Syndrome. West J Emerg Med. 2009 Feb; 10(10):6-10.

2. National Center for Injury Prevention and Control. Report to Congress on Mild Traumatic Brain Injury in the United States: Stepsto prevent a Serious Health Problem. Atlanta, GA: CDC; 2003.

3. UPMC Sports Medicine. Concussion Facts and Statistics. http://www.upmc.com/Services/sports-medicine/services/concussion/Pages/facts-statistics.aspx. Accessed 4/18/18.

4. NCAA. Concussion and College Sports. http://www.ncaa.org/about/resources/media-center/feature/concussion-and-college-sports. Accessed 4/18/18.

5. O’Neil ME, Carlson K, Storzbach D, et al. Complications of Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review. Department of Veterans Affairs (US): 2013 Jan. https://www.ncbi.nlm.nih.gov/books/NBK189784/.

6. Giza C, Hovda D. The Neurometabolic Cascade of Concussion. J Athl Train. 2001 Jul-Sep; 36(3): 228-235.

7. Kontos AP, Elbin RJ, Covassin T, Henry L, Pardini J, Collins MW. A Revised Factor Structure For the Post-Concussion Symptom Scale: baseline and post-concussion factors. Am J Sports Med. Oct; 40(10): 2375-84.

8. Concussion Legacy Foundation. What is CTE? https://concussionfoundation.org/CTE-resources/what-is-CTE. Accessed 4/20/18.

9. Knox County Parks & Recreation. Youth Sports Concussion Policy: Adapted from the Tennessee Secondary School Athletic Association Concussion Policy. https://www.knoxcounty.org/parks/pdfs/youth_concussion_policy.pdf. Accessed 4/16/18.

10. American Physical Therapy Association. The Physical Therapist’s Role in Management of the Person with Concussion. House of Delegates. June 12, 2012. Vote 10.

References