The Growing Epidemic of Concussion A Discussion of the Role of Physiotherapy

in its Recognition and Management

Presented March 23, 2013 by: Laura Lundquist Steve MacNeil

Laura Lundquist Graduated with MScPT from McMaster University (2003)

Advanced Diploma in Manual and

Manipulative Therapy (2009)

Diploma in Sport PT (2010)

Selected to the Canadian medical team for the Pan American Games (Guadalajara, 2011) and the FISU World University Games (Kazan, 2013)

Worked with the national rugby program (2011-12)

Steve MacNeil Graduated Dalhousie University with BScPT in 2004

Advanced Diploma in Manual and Manipulative Therapy 2011

Vestibular Rehabilitation Competency – Emory University Division of Physical Therapy

Co-owner of Atlantic Balance and Dizziness Centre since 2008

Goals for the Day

Improve skills in concussion assessment (both in-clinic and on-site) Gain knowledge and practical skills for management of concussion symptoms Be able to guide a client through his/her return to full function

Session Overview Epidemiology of concussion

Acute (ie: on-field/sideline) assessment and management – Orthopedic considerations

Follow-up (ie: in-clinic) assessment and management – Orthopedic, vestibular and psychological considerations

Return to function – Work, school and sport

Points to consider for future research and management guidelines

Pop Quiz – True or False You can have a concussion without losing consciousness

You can lose consciousness (following impact) without having a concussion

An adult should rest for at least a week following a concussion before returning to any physical activity

Children still suffering concussion symptoms should do their schoolwork at home instead of going to school

A Definition of Concussion Mild traumatic brain injury (MTBI) Electrochemical/metabolic dysfunction in the

brain

Typically normal appearance on CT Scan and MRI studies Signs and symptoms reflect a functional

disturbance vs. a structural injury

A Definition of Concussion

Caused by: – Direct blow to the head, face, neck or jaw – Direct blow elsewhere on the body with an

“impulsive” force transmitted to the head (often through whiplash of the neck)

Epidemiology of Concussion Leading causes of mild traumatic brain injury (mTBI)

(seen in emergency departments)* – Falls – Motor vehicle trauma – Unintentional struck by/against objects – Assaults – Sports

Possible increased sport occurrence/recognition since 2000 but under-reporting/attendance at emergency departments

*Bazarian J, et al. Mild traumatic brain injury in the United States, 1998-2000. Brain Injury 2005; 19(2):85-91.

Concussion

Symptoms – Headache – Dizziness – Feeling dazed – Seeing stars – Sensitivity to light – Ringing in the ears – Tiredness – Nausea – Irritability – Confusion, disorientation

Concussion

Signs – Unusual emotions/personality change – Vacant stare – Poor memory/attention – Slurred or slowed speech – Decreased athletic performance – Poor reasoning – Increased fatigue/tiredness – Decreased level of consciousness

Acute Management of Concussion Vienna (2001) International Symposium on Concussion in Sport – International consensus panel meets for the first time

Discarded 20+ grading systems in favor of one internationally-recognized system of concussion assessment

SCAT (Sport Concussion Assessment Tool) generated

Specific return to play protocol devised

Revised in 2004 (Prague), 2008 (Zurich) and 2012 (Zurich)

Acute Management of Concussion Identification of at-risk individual – Contact/event seen or described – Abnormal behaviour – Report of symptoms

Pocket Concussion Recognition Tool (CRT) – Screening tool for non-healthcare professionals to determine

need for immediate removal from play – Determines need for physician referral – Replaced the Pocket SCAT

Sideline Assessment from SCAT3 – Similar to CRT but also includes Glasgow Coma Scale – Has adult/child versions

Pros & Cons of the Pocket CRT

PROS CONS Easy to administer by non-healthcare professionals

Maddocks questions not relevant to all sports/scenarios

Consistent testing across varied sports

Maddocks questions may need to be altered for children under 13 yrs

“Backs up” decision for removal from play

Long symptom list to go through

Crosby Hit Winter Classic

http://www.youtube.com/watch?v=eUQziwabMKkhttp://www.youtube.com/watch?v=eUQziwabMKkhttp://www.youtube.com/watch?v=eUQziwabMKk

Acute management of Concussion

If any signs or symptoms are present, the individual must be withdrawn from activity immediately

Must be closely monitored for initial 24 hours for potential deterioration – Consideration in sport: do they stay on the bench?

Make appropriate referral to physician/ emergency department

Educate individual/parent re: management/self-monitoring

Acute management of Concussion

Education – Body and brain rest required – Potential risk with early return to activity/school/work – Close monitoring for deterioration for several hours – No medication until physician evaluation – No driving until physician evaluation – No alcohol consumption – Monitoring for increasing/changing symptoms associated with

physical/cognitive activity – Reassurance that 80-90% recover within 7-10 days (may be

longer in children/adolescents)

Why is it unsafe to only educate the affected individual?

Acute management of Concussion Risk of early return to physical activity

– Premature return to physical activity can prolong symptomatic

period – Physical activity risks second contact/collision injury causing

diffuse cerebral swelling (commonly referred to as second impact syndrome)

Cascade of events leading to cerebrovascular

congestion and increased intracranial pressure

Can cause permanent cognitive damage, brainstem herniation and/or death

“Brandon” Video Clip

Break

In-Clinic/Follow-Up Assessment Assessment may occur days after concussive incident (fall/MVA/sport injury etc)

May present with other injuries and may or may not recognize a concussion has occurred May need multi-system assessment for confounding variables: – Orthopedic – Vestibular

Confounding Variables Orthopedic Injury

Assessment – Biomechanical dysfunction in the cervical spine

and/or TMJ – Muscular weakness (stabilizers and movers) – Cervical proprioception

Management – Manual therapy correction for mobility loss – Strengthening program for neck stabilizers in all

directions – Proprioception training and position control in varied

positions/environments (mobility/position control, wobble boards, bosu etc)

Cervical dysfunction

Persistent headache following concussion that is cervicogenic – Manual therapy – Neuromotor control exercises for

cervicoscapular region

Lusas et al Characterization of headache after traumatic brain injury Cephalalgia 2012;32:600-6 Jull et al A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27:1935-43

Confounding Variables Vestibular Involvement

The Balance System

Afferent Input Visual Somatosensory – Proprioception, Kinesthesia

Vestibular – Linear, angular acceleration – Sensitivity to gravity

The Balance System

Efferent Output Vestibulo-ocular reflex (VOR) – Maintain stable gaze

Vestibulospinal reflexes – Maintain postural control/balance

Vestibular involvement following mTBI

1. Damage to the peripheral vestibular

apparatus 2. Impaired function of the central structures

that integrate balance information • Evidence for both (Mallinson and Longridge, 1998)

Dizziness – Vertigo – illusion of motion – Spatial Disorientation (Gottshall, 2011) – Visual-vestibular mismatch (Mallinson 1998, 2005)

Imbalance/Disequilibrium (Guskiewizc 2001, Geurts 1996, Gagnon 1998)

– Darkness – Uneven surfaces

Audiological (Griffiths, 1979)

Signs/Symptoms of Vestibular Involvement

Dizziness and headache most common and persistent complaints (Yang 2007) Reported to occur 23-81% of cases within the first days of injury (Whitney et al, 2010, Alsalaheen 2012)

Persistent dizziness from 1.2 % at 6 months to 32.5 % at 5 years (Griffiths 1979, Kisilevski et al 2001, Masson et al 1996, Maskell et 2001)

Dizziness following mTBI

Study of 107 male high school athletes (Collins et at 2011)

– Dizziness was only on-field symptom associated with delayed recovery

Dizziness adversely affected GOSE scores at 1,2,4 and 8 weeks post-mTBI (Yang 2007)

Independent predictor of failure to return to work 6 months post-mTBI (Chamelian, 2004)

Dizziness and Recovery

Questionnaires

Dizziness Handicap Index (Jacobson, 1990) – Sensitive to subtle balance dysfunction in

mTBI (Gottshall et al 2003) – Predictive of disability (Kammerlind 2005, Honrubia 1996)

Activities-specific Balance Confidence Scale (ABC) (Powell, 1995) – Predictive of falls risk – Ceiling effect in youth (Alsalaheen, 2012)

Graded Symptom Checklist (Guskiewicz 2012)

Vestibular Testing

Neuro – Cranial Nerves – Cerebellar screening (SCAT3)

Vestibular – Head impulse test (Halmagyi, 1988) – Clinical DVAT – Fukuda’s step test (Fukuda, 1959) – Nystagmus battery

Balance

Static – CTSIB (Horak, 1987) – Balance Error Scoring Scale (BESS) (Guskiewicz

2004, 2005; Broglio 2008)

Dynamic – Dynamic gait index (DGI) (Shumway Cook 1995)

Ceiling effect in youth (Alslaheen, 2012) – Functional gait assessment (FGA) (Whitney 2004) – Berg Balance Scale (Berg, 1992)

BESS (Alsalaheen, 2012) Age 14-18 Percentile

5 25 50 75 95

Firm surface, feet together 0 0 0 0 0

Firm surface, single leg stand 0 1 2 4 7

Firm surface, tandem 0 0 0 1 4

Foam surface, feet together 0 0 0 0 1

Foam surface, single leg stance 2 5 7 10 10

Foam surface, tandem 0 1 3 4 7

Total BESS Score 4 10 13 18 24

Benign Paroxysmal Positional Vertigo (BPPV)

Nature – Brief spells of vertigo associated with changes

of head position – Most common etiology is head injury (Herdman

1990)

– Head injury most likely precipitating factor in younger adults (Sement 1988)

Success 74.8%, 93.8%, 98.4% (Macias et al, 2000)

BPPV

BPPV testing – (R) Hallpike position

Move at moderate speed into supine with head turned 45° and declined 30°.

Can tilt bed if insufficient cervical ROM.

© Atlantic Balance and Dizziness Centre, 2009

© Atlantic Balance and Dizziness Centre, 2009

Specific Concussion Assessment SCAT3 Card (Zurich 2012)

Designed for use by healthcare professionals for individuals who are 13 yrs of age and older Allows consistent assessment for signs/symptoms of concussion (including orientation and balance) Helpful to monitor change over time through healing period

SCAT3 Pros and Cons

Pros Cons

SCAT3 Pros and Cons

Pros Cons

Standardized testing First assessment does not consider baseline cognitive strength

Objective measurement

Time to administer

Allows follow up comparison to monitor for change

Not useful for children under 13 yrs (Child SCAT3 developed to address this)

Considers many facets of brain function (symptoms, cognition, balance etc)

Can create “false confidence” in ability to return to play

Concussion Management through Return to Full Function

During the symptomatic phase, brain and body rest continue to be the primary directive This rest may include limitations for: – Activities of daily living (ADLs)

Childcare, driving, housekeeping etc – Work – School (absence of 1-2 days commonly required) – Sport/Physical activity

Once signs and symptoms have resolved, a progressive return to function can begin

Return to Daily Function ADLs – Driving should be limited until attention, processing

speed and reaction time are normalized – Housekeeping should be progressively introduced – Recognize increased difficulty with multi-tasking (including childcare)

Work – Consider partial days to start – Start with less-demanding mental tasks – Extra caution when returning to occupations requiring

heavy equipment operation

Return to Daily Function School – Progressive return (ie: 1 class/day), “easier” classes first – Reduced overall workload and take frequent breaks (ie: homework etc) – No tests initially; once able, allow extra time for assignments/exams – Avoid busy/bright/loud environments (bus, cafeteria, music/gym class) – Full asymptomatic return to school before return to

sport – NS guidelines currently being developed – Ontario guidelines available at www.canchild.ca

Return to Sport Cornerstone guidance of the Consensus Panel

since 2001

Considered valid for children over 13 yrs of age – A longer period of asymptomatic rest may be beneficial for

children/teens, no specific guidelines yet

Requires complete symptom resolution before beginning a graduated reintegration into physical activity

Return to Sport Secondary Prevention

Mouthguards – Unsupported by the evidence

Additional/enhanced head protection – Unsupported by the evidence – Danger of risk compensation

Neck strengthening – Biomechanically reasoned – Not yet supported by evidence

Rule changes in sport

Promotion of fair play/respect

What happens if this doesn’t work?

10-15 % will have persistent symptoms >10 days (Zurich 2012)

Management of Persistent Symptoms (Zurich 2012)

Symptoms are not specific to concussion Multidisciplinary management Consider re-assessment of other causes – Cognitive/psychological – Orthopedic (ie cervical) – Vestibular

Consider graded exercise program that does not exacerbate symptoms

Psychological Considerations

Emotional trauma regarding the injury Sense of loss – Cognitive, physical and sport impairment

Fear of permanent loss Can lead to depression, anxiety, somatization, dissociation, conversion and PTSD (Alexander et al 1993) These factors associated with delayed recovery (Jackson et al 2011)

Active Rehabilitation

Leddy et al Clin J Sport Med, 2010 Baker et al Rehabil Res Pract, 2012 Balke protocol – treadmill test to determine subsymptom level of activity (HR) – Instructed to exercise below that level

Studies lacked controls and randomization

Persistent Vestibular Symptoms

Customized program of exercise based on impairment (Hoffer 2004, Gotshall 2005, 2011, 2012, Gizzi 1995, Ernst 2005)

– Gaze stability - VOR, COR, oculomotor – Graded exposure to motion – Balance retraining

Improvement in balance function and self-reported dizziness scores (Whitney et al 2010, Hoffer et al 2004 + 2011, Gotshall 2005, Gurr and Moffat 2001, Herdman 1990, Shepard et al 1993, Gizzi 1995)

Randomized Controlled Trial

Schneider K et al Cervico-vestibular physiotherapy in the treatment of individuals with persistent symptoms following sport related concussion: a randomized controlled trial. Clin J Sport Med 2013;47e1

– 8 week program consisting of manual therapy, vestibular

rehabilitation, sensorimotor and neuromotor training – Controls had rest and then gradual exertion

– 1 of 14 control subjects were medically cleared at 8 weeks – 11 of 15 treatment subjects were medically cleared at 8 weeks

Wish-list of Testing

Vestibulonystagography (VNG) – Caloric – Oculomotor – DVAT

Rotary Chair testing Computerized Dynamic Posturography (Nashner 1990, Guskiewicz 2001, 2008)

– SOT – MCT

Mallinson (2005) Criteria for Aphysiological Behaviour

Criterion Description

1 Better performance on Conditions 1 and 2 when unaware

2 Conditions 1 and 2 markedly below normal

3 Conditions 5 and 6 relatively better than Conditions 1 and 2

4 Circular sway without any falls

5 High intertrial variability in all SOT trials

6 Repeated suspiciously consistent way patterns throughout SOT trials

7 Exaggerated MCT responses

8 Inconsistent MCT responses

9 “Gut feeling” (ie clinical judgment)

5 aphysiological behaviour

Points to Consider for Future Research and Development

Concrete return to work and school guidelines

Evaluation of the new assessment tool for the pediatric (5-12 yrs) population

More randomized controlled trials for slow to recover patients

Further determination of benefit of baseline testing in sport; selection of universal test

Revisiting the Pop Quiz – True or False

You can have a concussion without losing consciousness

You can lose consciousness (following impact) without having a concussion

An adult should rest for at least a week following a concussion before returning to any physical activity

Children still suffering concussion symptoms should do their schoolwork at home instead of going to school

Resources for Additional Information

http://bjsm.bmj.com/content/47/5/250.full.pdf+html (2012 Zurich Concussion Consensus Statement including SCAT2 template) http://www.cdc.gov/concussion/index.html (CDC guidelines for management) http://canchild.ca/en/ourresearch/mild_traumatic_brain_injury_concussion_education.asp (Concussion ON guidelines for management) http://www.cihi.ca/cihi-ext-portal/pdf/internet/pdf_analysis_ntr_2006_en (Canadian Institute for Health Information re: epidemiology of head injury in Canada)

http://bjsm.bmj.com/content/47/5/250.full.pdf+htmlhttp://www.cdc.gov/concussion/index.htmlhttp://canchild.ca/en/ourresearch/mild_traumatic_brain_injury_concussion_education.asphttp://www.cihi.ca/cihi-ext-portal/pdf/internet/pdf_analysis_ntr_2006_enhttp://www.cihi.ca/cihi-ext-portal/pdf/internet/pdf_analysis_ntr_2006_enhttp://www.cihi.ca/cihi-ext-portal/pdf/internet/pdf_analysis_ntr_2006_enhttp://www.cihi.ca/cihi-ext-portal/pdf/internet/pdf_analysis_ntr_2006_enhttp://www.cihi.ca/cihi-ext-portal/pdf/internet/pdf_analysis_ntr_2006_en

Questions?

Thank you!

The Growing Epidemic of Concussion�A Discussion of the Role of Physiotherapy �in its Recognition and ManagementLaura LundquistSteve MacNeilGoals for the DaySession OverviewSlide Number 6A Definition of ConcussionA Definition of ConcussionEpidemiology of ConcussionConcussionConcussionAcute Management of ConcussionAcute Management of ConcussionSlide Number 14Pros & Cons of the Pocket CRTSlide Number 16Crosby Hit �Winter ClassicAcute management of ConcussionAcute management of ConcussionAcute management of Concussion“Brandon” Video ClipBreakIn-Clinic/Follow-Up AssessmentConfounding Variables �Orthopedic InjuryCervical dysfunctionConfounding Variables �Vestibular InvolvementThe Balance SystemThe Balance SystemVestibular involvement following mTBISigns/Symptoms of Vestibular InvolvementDizziness following mTBIDizziness and RecoveryQuestionnairesVestibular TestingBalance Slide Number 36BESS (Alsalaheen, 2012)Benign Paroxysmal Positional Vertigo (BPPV) BPPVBPPV testing – (R) Hallpike positionSlide Number 41Slide Number 42Specific Concussion Assessment�SCAT3 Card (Zurich 2012)Slide Number 44Slide Number 45SCAT3 Pros and ConsSCAT3 Pros and ConsConcussion Management through Return to Full FunctionReturn to Daily FunctionReturn to Daily FunctionReturn to SportSlide Number 52Return to Sport �Secondary PreventionWhat happens if this doesn’t work?Management of Persistent Symptoms (Zurich 2012)Psychological ConsiderationsActive RehabilitationPersistent Vestibular SymptomsRandomized Controlled TrialWish-list of TestingSlide Number 61Mallinson (2005) Criteria for Aphysiological BehaviourPoints to Consider for Future Research and DevelopmentSlide Number 64Resources for �Additional InformationQuestions?