school of medicine - u of u school of medicine | …consensus statement on concussion in sport—the...

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HOW TO ASSESS THE NEED FOR THERAPY IN THE RECOVERY FROM

CONCUSSION?RYAN PELO, PT, DPT, NCS


DISCLOSURE

• I have no actual or potential conflict of interest in relation to this program/presentation

• I am an employee of the University of Utah and have no financial interests or relationships to disclose


OBJECTIVES

• Discuss the timeline and pathophysiology of concussion

• Discuss the common clinical trajectories after concussion

• Provide assessments of each clinical trajectory that can be performed during an evaluation

• Discuss the indications for referral to therapy specialties in the treatment of concussion


WHAT ARE WE MISSING?

• Athletes with a previous concussion are 50-70% more likely to experience a musculoskeletal injury compared to teammates without a recent concussion

Cross et al., 2016, Lynall et al., 2015, Lynall et al., 2017, Nordstrom et al., 2014, Fino et al., 2017


THE CONCUSSION TIMELINE

• Concussion is a functional disturbance rather than a macrostructural brain injury, the resolution of which requires 7 to 10 days in the typical athlete (80%–90% of cases)

• After a brief period (24–48hours) of complete rest, patients can be encouraged to become gradually and progressively more active

Leddy et al., 2017, Giza & Hovda, 2001, Schneider et al., 2017


EDUCATION

• How Hard to Push Yourself

• Concussion as an Earthquake

• What Areas Do We Need to Assess


HOW HARD CAN I PUSH MYSELF?

1 MINUTE RULE• Identify when an increase in symptoms occurs• Stop activity and time how long it takes to

return to baseline• The goal is for a return to baseline within 45-60

seconds• If it takes longer than 60 seconds to recover,

take a break sooner or modify the task • If it takes less than 45 seconds to recover,

increase symptom intensity before taking a break


EDUCATION





CONCUSSION AS AN EARTHQUAKE

CONCUSSION(earthquake)

Dizziness(water/sewer)

Memory(phone lines)

Balance(roads)

Headache(electrical)


EDUCATION





PREVALENCE OF IMPAIRMENTS

• 47-60% visual changes • 82.9% cervical dysfunction• 26.8% cervicogenic dizziness• 20-58% dizziness• 47-95% headache• 74% memory deficits• 68% mood changes

Reneker et al 2018, Reiley et al 2017, Ventura, Balcer, & Galetta, 2015, Sussman et al. 2016, Gallawayet al., 2016, Capo-Aponte, et al., 2012, Defrin, 2014, Colantonio & Comper, 2012


• Identifying the symptom generator(s) in the athlete is essential to prescribing appropriate active therapy

• The clinical assessment of sport related concussion (SRC) should be symptom based and interdisciplinary. Whenever possible, the SRC assessment should incorporate neurological, vestibular, ocular motor, visual, neurocognitive, psychological and cervical aspects

Feddermann-Demont et al., 2017, Leddy et al., 2017


CLINICAL TRAJECTORIES

Vestibular

Vision

Cervical

Migraine

Cognitive

Anxiety/Mood

Collins et al., 2014



Vestibular

Vision

Cervical

MigraineCognitive

Anxiety/Mood

Physiologic



PHYSIOLOGIC

• Physiologic dysfunction after TBI is believed to represent some degree of uncoupling between the brain autonomic centers and the cardiovascular system

• The patient with physiological dysfunction to typically stops well short of the age-predicted maximum HR because he or she simply cannot continue to exercise for reasons other than physical exhaustion.

Goldstein et al., 1998, Clausen et al., 2016


BUFFALO CONCUSSION TREADMILL TEST

• The Buffalo Concussion Treadmill Test (BCTT) is based on the Balke cardiac treadmill stress test and imparts a very gradual increase in workload

• Start at speed of 3.3-3.6mi/h• Increase incline by 1% each minute• Record HR each minute• Record RPE each minute• Record Symptom Level each minute

TEST SHOULD BE STOPPED IF:• SYMPTOMS INCREASE 3 POINTS ABOVE INITIAL SYMPTOM SCORE• RPE INCREASES TO 19/20• AGE PREDICTED HR MAX IS REACHED

Leddy et al., 2010


MODIFIED ORTHOSTATIC VITALS

• Vitals performed after supine for 5min, then performed after transition to standing for 5min

Orthostatic Intolerance is indicated if:• Increase in HR of >30bpm (40bpm for under 14)• Standing HR >120bpm (130bpm for under 14)• Decrease of >20 mm Hg in systolic BP• Decrease of >10mm Hg in diastolic BP

Kizilbash et al., 2014


WHEN TO REFER TO THERAPY

• Buffalo Concussion Treadmill Test– Test is stopped due to symptoms and not due to

RPE or HR Max

• Modified Orthostatic Vitals– If orthostatic intolerance is indicated by

parameters

• Patient reports increased symptoms with any type of exercise



Vestibular

Vision

Cervical

MigraineCognitive

Anxiety/Mood

Physiologic



VESTIBULAR/VISION/BALANCE

• Vestibular rehabilitation should be considered in the management of individuals post concussion who have dizziness, gait and balance dysfunction that do not resolve with rest

• Visual rehabilitation can be of benefit post-concussion for patient with blurring of vision, diplopia, photophobia/difficulty with glare, difficulty focusing, difficulty reading, difficulty with tracking objects

Alsalaheen et al., 2010, Gottshall, 2011, Pillai & Gittinger, 2017


VESTIBULAR OCULAR MOTOR SCREEN (VOMS)

Mucha et al., 2014


BALANCE ERROR SCORING SYSTEM(BESS) TEST

Bell et al., 2011


COBALT

• Error is counted if:– Step out of testing position– Eyes open during eyes closed task– Speed of head or shoulder rotation is not maintained

• Head shaking = 180bpm• Visual motion sensitivity = 50bpm

Massingale et al., 2018

FIRM SURFACE1. Eyes open2. Eyes closed3. Head shaking4. Visual motion sensitivity

FOAM SURFACE5. Eyes open6. Eyes closed7. Head shaking8. Visual motion sensitivity



• VOMS– Near Point Convergence ≥ 5cm– Symptom score ≥ 2pts on any item

• BESS– Greater than 10-12 errors

• COBALT– Greater than 1 error on any item

Guskiewicz et al., 2001, McCrea et al., 2003, Iverson et al., 2008, Massingale et al., 2018, Mucha et al., 2014



Vestibular

Vision

Cervical

MigraineCognitive

Anxiety/Mood

Physiologic



CERVICAL

• Neck injuries and concussion happen concurrently

• Treating cervical spine pain improves participation in vestibular and vision therapy

• Currently, there is no gold standard for the diagnosis of cervicogenic dizziness; therefore, it is a diagnosis of exclusion based on history, behaviors, and a clinically identified cluster of signs and symptoms.”

Marshall et al 2015, Schneider et al 2014, Jung et al., 2017


CERVICAL ASSESSMENT

• Postural Assessment• Cervical AROM• Palpation/flexibility of upper quarter– Trigger points– Referred pain reproducing

headache/dizziness • Head Neck Differentiation Test– Patient sits on a chair that rotates– Chair and body rotated to left side then right

side while examiner holds the head stillCheever et al 2016



• Neck pain• Headache• Dizziness• Limited cervical ROM• Painful cervical ROM• Upper quarter muscular or myofascial pain• Tingling/numbness in the UEs• Symptoms with Head Neck Differentiation

Test



Vestibular

Vision

Cervical

MigraineCognitive

Anxiety/Mood

Physiologic



COGNITIVE/MEMORY

ReceptiveLISTENING AND READING

ExpressiveSPEAKING AND WRITING

Attention

Information Processing

EncodingWord and Rule

RetrievalThought Formulation

Organization


IMPACT

• ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing)

• Most commonly used, computer neurocognitive test to help evaluate and manage concussions

• Used by more than 7,400 high schools, 1,000 colleges and universities, 900 clinical centers, 200 professional teams and select military units.

• FDA cleared for ages 5-59, separate pediatric version


STANDARD ASSESSMENT OF CONCUSSION (SAC)

Valovich et al., 2006


POST CONCUSSION SYMPTOM SCALE (PCSS)

• Self report scale, a way to more objectively document subjective symptoms often reported by concussion patients.

• 22 questions, 0-6 Likert scale. Total out of 132.

• Subsections: Headache, Vestibular, Emotional, Cognitive, Sleep.

Lovell, 2006



• SAC– Less than 26pts

• PCSS– Men, greater than 12pts– Women, greater than 20pts

Valovich et al., 2006, Lovell et al. 2006


TESTING BATTERY

• Physiologic– Buffalo Concussion Treadmill Test– Modified Orthostatic Vitals

• Vestibular/Vision/Balance– VOMS– BESS– COBALT

• Cervical– Postural Assessment– Cervical AROM– Palpation/flexibility of upper quarter– Head Neck Differentiation Test

• Cognitive/Memory– ImPACT– SAC– PCSS


WHY IS A COMPREHENSIVE BATTERY IMPORTANT

• 60-70% have a musculoskeletal post-concussion compared to athletes without recent concussion

• Need to be more comprehensive in our approach to evaluation and use of therapy further evaluation and treatment


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