CONCUSSION: The Good the Bad, and the Ugly Cristin Bealzey, PT, DPT, CBIS Sheltering Arms – Total Concussion Care.

CONCUSSION: The Good the Bad, and the Ugly Cristin Bealzey, PT, DPT, CBIS Sheltering Arms – Total Concussion Care

Learning Objectives Identify common symptoms and the physiology associated with concussion injury Identify each interdisciplinary team members role in concussion management. Identify the core components of concussion management. Identify the physical therapist role in concussion management. Identify common red flags that warrant referral to alternative healthcare professionals. Identify the key components to a return to play protocol which fully test the vestibular system and increase the likelihood of complete concussion recovery prior to return to play.

Who am I? Graduated from JMU with degree in Athletic Training 2003
Graduated from VCU PT school with DPT in 2006 10 years clinical experience – 5 years experience at Children’s Hospital of Richmond, including 5 years of concussion treatment Started with Sheltering Arms in October 2012 Lead Concussion Clinician for Total Concussion Care Program at Sheltering Arms.

Concussion overview

Why Concussion? Long neglected population
CONSTANTLY evolving and developing area of practice It is an injury that covers a wide spectrum of patient populations Effects can be debilitating and with proper intervention can improve patient function and return to prior functional levels Wide spread media attention

Definition Concussion
Complex pathophysiologic process affecting the brain Induced by traumatic biomechanical forces 2o direct or indirect forces to the head. Constellation of physical, cognitive, emotional or sleep-related symptoms, +/- LOC. Neuroimaging typically normal Duration of symptoms is highly variable - from several minutes to days, weeks, months, or longer in some cases Findings for over 90% of CTs and structural MRIs are negative. The use of radioisotope injection based imaging scans, including single-photon emission tomography (PET) may be included to assess cerebral blood flow and brain glucose levels if desired – however they are not clinically validated. *Center for Disease Control and Prevention: Heads up: Brain injury in your practice, Updated 2007 * West TA , Marion DW, Current Recommendations for the Diagnosis and Treatment of Concussion in Sport: A Comparison of Three New Guidelines, Journal of Neurotrauma 31: , January 15, 2014. Property of Sheltering Arms. Do not alter, copy or use without permission

Definition Postconcussion Syndrome (PCS)
collection of symptoms that occur after a concussion, symptoms that persist longer than 3 weeks* Two clinical criteria International Classification of Diseases (ICD-10) DSM-IV *Willer B, Leddy JJ. Management of concussion and post-concussion syndrome. Curr Treat Options Neurol 2006;8: *Collins M, Lovett M, et al. Examining concussion rates and return to play in high school football playerswearing newer helmet technology: A threee-year prospective cohort study. Neurosurgery 2006;58: Property of Sheltering Arms. Do not alter, copy or use without permission

DSM-IV-TR Criteria for Postconcussional Disorder
A. A history of head trauma that has caused significant cerebral concussion. B. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks), or memory (learning or recalling information). C. Three (or more) of the following occur shortly after the trauma and last at least 3 months: Becoming fatigued easily Disordered sleep Headache Vertigo or dizziness Irritability or aggression with little or no provocation Anxiety, depression, or affective lability Changes in personality (eg, social or sexual inappropriateness) Apathy or lack of spontaneity D. The symptoms in criteria B and C have their onset following head trauma or else represent a substantial worsening of preexisting symptoms. E. The disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. In school-aged children, the impairment may be manifested by a significant worsening in school or academic performance dating from the trauma. F. The symptoms do not meet criteria for dementia due to head trauma and are not better accounted for by another mental disorder (eg, amnestic disorder due to head trauma, personality change due to head trauma). Property of Sheltering Arms. Do not alter, copy or use without permission

ICD-10 Criteria: Postconcussion Syndrome
History of TBI Presence of 3 or more of the following 8 symptoms: (1) headache (2) dizziness (3) fatigue (4) irritability (5) insomnia (6) concentration (7) memory difficulty (8) intolerance of stress, emotion, or alcohol Property of Sheltering Arms. Do not alter, copy or use without permission

Synonyms Mild TBI (mTBI) – WHO, ACRM Concussion & Sports concussion – AAN Mild CHI – American Academy of Pediatrics Property of Sheltering Arms. Do not alter, copy or use without permission

Epidemiology Incidence rate
Majority of TBI are mTBI or concussions (75-85%) Annual rate of mTBI is per 100,000 persons Approximately 300,000 sports-related concussions occur in the United States every year Public health & cost Estimated annual cost (direct and indirect) in U.S = $ billion Negative effect on psychological well being and health related quality of life (HRQOL) Higher family burden and emotional distress ( Property of Sheltering Arms. Do not alter, copy or use without permission

Impact of Concussion 225,000 new persons each year show
LONG TERM deficits as a result of mTBI (Meaney 2011) -The people who are experiencing these deficits are children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older as they are most likely to sustain a TBI. -It is estimated that ~ 10% will have post concussion syndrome - defined by the World Health Orgonization as the persistence of 3 or more of the following symptoms after suffering at TBI: Headache, dizziness, fatigue, irritabiilty, insomnia, as well as concentration and memory difficulties. These are the people that are treated with PT. Property of Sheltering Arms. Do not alter, copy or use without permission

Age-Specific Considerations
70.5% of sports & recreation-related TBI ED visits were among persons aged years. This age group requires clear guidelines for: activity modifications academic accommodations Goal: Return to previous levels of activity However, with athletes in particular, it is essential to take them through a progressive, stepwise return to play protocol to ensure safe return to play. -These accommodations will allow them to participate in school and work to return to their previous levels of activity, decreasing the stress of missing school and falling behind. -Medical psychology plays a vital role in helping manage this from the beginning of the patient’s recovery -It is important to educate the parents because they are the ones that hopefully will help to support the recommended activity and academic accommodations – now we say hopefully because this is not always the case, makes it important to educate the patient as well as always but to make sure that more than one person is aware of the recommendations. Property of Sheltering Arms. Do not alter, copy or use without permission

Closer Look at the Injury
Glen Davis got injured in game 5 of the eastern conference finals in 2010 was able to play in game 6 3rd video Jahvid Best playing for California in 2009 – he was taken to the hospital and released the next day. It was released that he had actually suffered a concussion in the game the week before – had sat out practice on Tuesday and Wednesday but had full practice on Thursday before this injury Missed the rest of the regular season including the 2009 Pointsettia Bowl – announced on 1/2/2010 that he would forego his senior year and go to the NFL draft Drafted 30 overall to the Lions In 2011 – he suffered a concussion on his 2nd carry of the 3rd preseason game Suffered another concussion in the 2nd half of the October 16th game against San Francisco. That was the last NFL game he played. The Lions released him this past summer secondary to continuing to suffer post concussion symptoms. As of a quote in August he was still hoping to return to play and continue his career. He is currently a free agent and still undergoing treatment. He joined the Cal Bears coaching staff in January 2014.

Pathophysiology of Concussion
Metabolic crisis, resulting in an ↑ in energy demand with a ↓ in blood flow as a result of concussion. May also be diffuse shearing of the axons due to the movement of the brain within the skull It is important during this time of the crisis to not get hit again as well as to not stress the brain Cognitive and physical rest in the early stages of recovery. -There is still a lot of research looking at the physiology and mechanism of concussion. There is still a lot that is not known about the true mechanism; however we do know that it is considered a metabolic crisis that results in increase in energy demand with a decrease in blood flow. -Additionally, the suspected shearing of the axons of the brain during the insult secondary to the movement within the skull is thought to be not as severe as thought with other brain injuries. Imaging – CT scan, MRI all typically negative The only imaging to detect changes is the functional MRI as demonstrated by a study of over 200 high school athletes that were tested within 7 days of concussion and at their point of clinical recovery It was noted that hyperactivation predicts clinical recovery time Resolution of hyeractivation correlates with recovery on ImPACT (Immediate Post Concussion Assessment and Cognitive Testing) *ImPact is a computerized neurocognitive test which tests memory, processing speed, and reaction time. It will be reviewed further by our Medical Psychologist and PM&R MD. -This is an image of new technology that is being used experimentally at UPMC that is called high definition fiber tracking where it allows the brain and all the fibers to be mapped so doctors can look at the actual fibers and determine where the damage is to help pinpoint the impairments and how to intervene appropriately. Property of Sheltering Arms. Do not alter, copy or use without permission

Rest? ?? Recent study in Journal of Pediatrics from 11/14 looked at the benefits for strict rest after concussion Randomized controlled trial 99 pts age that presented to ED within 24 hours of concussion Completed neurocognitive, balance and symptom assessment in ED Randomized to: Intervention group – strict rest for 5 days and Control group – usual care, 1-2 days of rest and then gradual step wise return to previous activities Results Intervention group had less attendance for school and after school at days 2 and 5 No clinically significant difference on neurocognitive and balance assessments Intervention group reported more daily postconcussive symptoms ( over 10 days total score vs ) and slower symptom resolution Conclusion Recommending strict rest after concussion for 5 days added NO benefit to concussion recovery as compared to the usual care Patients completed a diary used to record physical and mental activity level, calculate energy exertion, and record daily postconcussive symptoms. Neurocognitive and balance assessments were performed at 3 and 10 days postinjury. Take away – rest is important however have to consider secondary factors that will affect recovery.

Symptoms & Symptom Management
Concussion management & recovery Focused on symptom management throughout Symptoms Predictors of outcomes and overall prognosis. Early stages of concussion recovery Monitor symptom progression, resolution and variability.

Symptoms & Symptom Management
In a 2006 study of a post concussion symptom scale, Lovell et. al. described 4 distinct categories of symptoms. cognitive symptoms somatic symptoms mood disruption sleep alterations **It is important to note as indicated by the diagram on the next slide that a person’s symptoms can change throughout recovery and can move between the categories They did a factor analysis of the symptoms scale and determined the categories. Cognitive symptoms – typically include difficulty with memory and fogginess, seen most often in the early stages Somatic symptoms – include headache and dizziness – that are frequently reported throughout the recovery. This is the area that PT typically addresses. Mood disruption: include irritability and anxiety – typically seen throughout however often increase and become more of a factor when recovery is prolonged. This is where education from the beginning as well as both medical psychology and PM&R can be very helpful in managing this area. Sleep alterations – this includes both difficulty with falling and staying asleep. This is one of the most important early symptoms to try to manage. This is probably one of the number one reasons that PT will refer to PM&R and that is for possible medication management to help the sleep dysregulation. We know for sure that patients will not start to report they are feeling better until they are sleeping consistently and effectively. Property of Sheltering Arms. Do not alter, copy or use without permission

Concussion Symptoms (Lovell 2006)
fogginess, difficulty concentrating, memory deficits, cognitive fatigue COGNITIVE SYMPTOMS Headache, dizziness, nausea, light/sound sensitivity SOMATIC SYMPTOMS irritability, feeling sad, anxiety MOOD DISRUPTION difficulty falling asleep, fragmented sleep, too much/little sleep SLEEP ALTERATIONS In a 2006 study of a post concussion symptom scale, Lovell et. al. described these 4 distinct categories of symptoms. -factor analysis of the symptoms scale to determine the categories. Cognitive symptoms – typically include difficulty with memory and fogginess, seen most often in the early stages Somatic symptoms – include headache and dizziness – that are frequently reported throughout the recovery. This is the area that PT typically addresses. Mood disruption: include irritability and anxiety – typically seen throughout however often increase and become more of a factor when recovery is prolonged. This is where education from the beginning as well as both medical psychology and PM&R can be very helpful in managing this area. Sleep alterations – this includes both difficulty with falling and staying asleep. This is one of the most important early symptoms to try to manage. This is probably one of the number one reasons that PT will refer to PM&R and that is for possible medication management to help the sleep dysregulation. We know for sure that patients will not start to report they are feeling better until they are sleeping consistently and effectively. **It is important to note as indicated by the diagram on this slide that a person’s symptoms can change throughout recovery and can move between the categories Property of Sheltering Arms. Do not alter, copy or use without permission

What Affects Recovery? Adolescents more vulnerable STRESS!!!!
Past Medical History Previous concussions Migraines Visual impairments ADHD/Learning disability Mood disorders Symptoms at time of injury Dizziness* Amnesia LOC Fogginess (Lau et al 2011) Age Exertion Gender Migraine Repetitive concussion Acute markers of TBI: LOC, amnesia, confusion Subacute symptoms -Memory problems & fogginess -Anxiety & noise sensitivity As mentioned earlier – adolescents make up a significant percent of this population and it is has been found in the research that they tend to be more vulnerable to a prolonged recovery. However, clinically what we have seen is that the age is not always the issue but the amount of stress that a person experiences and is under can directly affect the recovery process. This is why it became so important to have medical psychology involved from the beginning. Dizziness at the time of injury is another prognostic indicator supported by research which will be elaborated on in upcoming slides Property of Sheltering Arms. Do not alter, copy or use without permission

Prognosis and Recovery with Concussion
Concussion recovery can be highly variable Treatment is time sensitive secondary to the scope of functioning People post-concussion report that everything is affected Ability to sleep Ability to think clearly Ability to concentrate Ability to interact with a variety of environments According to research Old research (Collins et al 2006, Neurosurgery) 80% of all concussion recovery within 21 days New research (Henry LC et al, 2016, Neurosurgery) When the recommended "comprehensive" approach is used for concussion assessment, recovery time for SRC is approximately 3 to 4 weeks, which is longer than the commonly reported 7 to 14 days - It is important to track the report of symptoms and use best clinical research to educate patients on what may affect their overall recovery According to research that looked at resolution of symptoms and return to baseline performance on neurcognitive computer testing: typical recovery was determined to have 80% recovering within 21 days and those that fall outside of that timeline are considered to have a protracted recovery. At the time of this research computerized neurocognitive testing, especially ImPACT, was considered to be one of the gold standards for recovery with concussion. Since that time it has been found that it is only one piece of the puzzle and needs to be used in conjunction with vestibular evaluation, symptom reporting and balance testing. Additionally, with clinical practice at SAH, we find that many patients continue to have problems with RTP or other symptoms even if ImPact testing has returned to normal. Recovery time across all outcomes was between 21 and 28 days after SRC for most athletes. Symptoms demonstrated the greatest improvement in the first 2 weeks, although neurocognitive impairment lingered across various domains up to 28 days after SRC. Vestibular-oculomotor decrements also resolved between 1 and 3 weeks after injury. There were no sex differences in neurocognitive recovery. Male subjects were more likely to be asymptomatic by the fourth week and reported less vestibular-oculomotor impairment than female subjects at weeks 1 and 2. Property of Sheltering Arms. Do not alter, copy or use without permission

Clinical Trajectories
Risk Factors Previous concussions Migraine LD/ADHD Sex Age Motion Sensitivity/Ocular history Concussion Clinical Trajectories Vestibular Ocular Cognitive Anxiety/Mood Cervical Treatment and Rehab Pathways Medication management Vestibular Therapy Vision therapy Exercise prescription Article by Collins, Kontos et al. That was published in 2013 described a new method for conceptualizing treatment for sport related concussion using clinical experience. So they looked at current literature of sport related concussion and combined with clinical experience they developed an approach to management using clinical trajectories and targeted treatments. This is an interesting concept because as mentioned already concussion presentations are highly variable. There is a saying if you have treated one concussion, you have treated one concussion. Now there have also been other studies, in particular by Leddy et all out of Buffalo that looked at breaking down concussion by symptom report alone and focused on differentiating between physiological concussion with its vestibular and cervical counterpoints. That study found that it could not be differentiated by symptom report alone. This looked at symptom report in a little more detailed fashion and requires the clinician to take a very detailed and ask specific concussion related questions. The history aims to gather more information regarding a person’s history of risk factors as a prognositic indicator, details surrounding the actual injury followed by a comprehensive assessment and based on the above being able to place them in the appropriate clinical trajectory. I warn to be careful with this because it is not an absolute and you will continue to find overlap. It is also not uncommon with concussion for symptoms to change throughout the recovery process and it is essential to always be aware of mitigating factors that can affect a person’s recovery. I brought this up so that you are aware that these exist and can help to guide treatment and management, however based on the breadth of information I need to cover I will advise that if you want more information to read the article – as it is a very good resource.

Physician Specialists Medical Psychologist, Neuropsychologist
It takes a village… Student Athlete Parents Pediatrician Physician Specialists Medical Psychologist, Neuropsychologist Physical Therapist Coach Athletic Trainer Counselor Teacher School Community

Approach to Concussion Treatment
Interdisciplinary/Multimodal Primary care/Pediatrician/ER initial diagnosis ATC for sideline assessment and RTP PT – Vestibular/Cervical eval & rehab, RTP protocol Medical psychologist – neurocognitive testing and supportive counseling/psychotherapy Medical management No FDA approved medications “start low, go slow” Ongoing research but still limited evidence Weekly team conferences Property of Sheltering Arms. Do not alter, copy or use without permission

Current sideline assessments
Concussion Current sideline assessments

Sideline Assessments According to the Consensus Statement on Concussion In Sport, sideline assessment is an essential component of treatment of concussion. Sideline assessments should be performed immediately following any needed first aid assessment. Some examples include the following: King Devick Test SCAT-3 SAC Military Acute Concussion Evaluation Balance Error Scoring System (BESS) Clinical Reaction Time

King Devick Test Remove from play sideline assessment
Parents or coaches can administer 2 minute test Athlete must read single digit numbers across cards or an iPAD Any deviation from baseline score results in recommendation for remove from play for further evaluation by a licensed professional Screens for: Saccades (eye movements) Attention Concentration Speech/Language Other areas of brain function Vision testing is additive to the sideline assessment of sports – related concussion -Among 30 athletes with first concussion during their athletic season (n = 217 total), differences from baseline to postinjury showed worsening of K-D time scores in 79%, while SAC showed a ≥2-point worsening in 52%. Combining K-D and SAC captured abnormalities in 89%; adding the BESS identified 100% of concussions. Adding a vision-based test may enhance the detection of athletes with concussion.

Progressively get harder with each card
King Devick Cards

Sport Concussion Assessment Tool – 3rd Edition (SCAT-3)
Standardized assessment SCAT-3 for ages >13 years old Child SCAT-3: ages 5-12 Designed to be done by a medical professional 8 items Comprised of the following categories Symptom score Cognitive assessment Neck evaluation Balance Assessment Coordination Examination Delayed recall According to the Consensus Statement on Concussion In Sport: It appears that the SCAT -3 is comprehensive as a sideline assessment to address medical history, a neurological examination including a thorough assessment of mental status, cognitive functioning, gait, and balance

Balance Error Scoring System (BESS)
Full version and modified Full includes conditions for both eyes open (EO) and eyes closed (EC): modified just EC 3 foot positions Feet together Tandem stance Single leg stance (SLS) Firm vs. Foam Surface # of errors counted for each trial of 20 seconds

BESS Test BESS test designed specifically for concussed athletes – accurate only within 1-3 days post injury (Broglio 2009, Peterson 2003) Recent systematic review determined that the BESS has moderate to good reliability to assess static balance. However it also determined that is better at determining large balance changes and not as accurate at detecting subtle changes. (Bell et al, 2011)

TYPICAL MEDICAL MANAGEMENT
Sideline testing: MD vs. ATC Symptom management Balance Testing Neurocognitive testing Computer-based testing Cogsport ANAM Concussion Vital Signs ImPACT* MD/ER visit Imaging CT scan/MRI (Functional MRI) Typically negative Cognitive Rest How long? 2 weeks? Until symptoms go away? Medications OTC, prescription School Accommodations Referral to PT So traditional medical management of concussion is as follows. Any typically some, all or none of it happen with the exception of the MD visit before they get to us. The treatment by the medical community continues to be highly varied for management of concussion.

Concussion Medical management

Assessment & Diagnosis
Concussion History Comorbidities Complicating Factors Symptoms Multidimensional Assessment Balance Postural Stability Cognition (Echemendia RJ, et al. Br J Sports Med 2013) Property of Sheltering Arms. Do not alter, copy or use without permission

Assessment & Diagnosis
HPI and PE Post-Concussion Symptom Scale (Pardini et al. 2004) Clinical testing – balance, VOR, endurance Neurocognitive assessment Property of Sheltering Arms. Do not alter, copy or use without permission

(Pardini D, et al. Br J Sports Med 2004)
Property of Sheltering Arms. Do not alter, copy or use without permission

Post-Concussion Symptom Scale Sleep cycle dysfunction
Trouble falling asleep Too much/little sleep Fragmented sleep Somatic Symptoms Headache Dizziness/ balance Nausea Light /noise sensitivity Tired, low energy Blurred vision Cognitive symptoms Concentration Memory Fogginess Cognitive fatigue/slowing Mood Disruption Irritability Sadness Anxiety/nervousness Emotional lability (Pardini D, et al. Br J Sports Med 2004) Property of Sheltering Arms. Do not alter, copy or use without permission

Approach to Concussion Treatment
Individualized management standardized concussion grading scales  neurocognitive testing & comprehensive symptom evaluation Cornerstones of treatment: Cognitive & physical rest Education Therapy Property of Sheltering Arms. Do not alter, copy or use without permission

Sleep cycle dysfunction
Somatic Symptoms Sleep cycle dysfunction Trouble falling asleep Too much/little sleep Fragmented sleep Somatic Symptoms Headache Dizziness/ balance Nausea Light /noise sensitivity Tired, low energy Blurred vision Cognitive symptoms Concentration Memory Fogginess Cognitive fatigue/slowing Mood Disruption Irritability Sadness Anxiety/nervousness Emotional lability Property of Sheltering Arms. Do not alter, copy or use without permission

POST-TRAUMATIC HEADACHE (PTH)
Somatic Symptoms POST-TRAUMATIC HEADACHE (PTH) Most common reported symptom of concussion = 85% International Classification of Headache Disorders Secondary headache Types: Cervicogenic Fatigue-related HA MSK : myosfascial/tension Nerve injury (Greater occipital nerve) Post-traumatic migraine Rebound HA : medication induced Property of Sheltering Arms. Do not alter, copy or use without permission

Somatic Symptoms Myofascial/Musculoskeletal/Tension headache
Medications : NSAIDs, analgesics, muscle relaxants Trigger point injections Greater occipital nerve blocks PT : myofascial release, muscle energy techniques, massage, modalities, TENS Acupuncture Relaxation and meditation techniques Biofeedback & behavior modification Property of Sheltering Arms. Do not alter, copy or use without permission

Somatic Symptoms Migraine Abortives
Sumatriptan (Imitrex) mg/dose, max 200 mg/day, oral/inhaled Rizatriptan (Maxalt) 5-10mg/dose, max 20 mg/day Prevention/Treatment Antidepressants Amitriptyline (Elavil) mg Escitalopram (Celexa) mg Sertaline (Zoloft) mg Venlafaxine (Effexor) mg, XR 37.5 – 150 mg Property of Sheltering Arms. Do not alter, copy or use without permission

Somatic Symptoms Migraine Anticonvulsants
Topiramate (Topamax) - 25 mg/day x 1week, 25 mg BID, increase 25 mg/day weekly Valproic acid – 250 mg BID Gabapentin – 300 mg/d, inc to TID prn, non-FDA approved indication Beta blockers – propranolol Property of Sheltering Arms. Do not alter, copy or use without permission

Somatic Symptoms Rebound headache
Increased incidence in patients with chronic PTH Most common: opioids, butalbital-containing combination analgesics & ASA/APAP/caffeine combinations Opiates : risk of transformation from episodic HA to chronic, greater in men & use 8 days/month APAP greater risk than NSAIDS & triptans APAP – acetiminophan ASA - aspirin Property of Sheltering Arms. Do not alter, copy or use without permission

Somatic Symptoms Concussion “supplements”
Chronic supplementation (3-6 months) may decrease frequency & severity of primary HA, not studied in PTH Alpha lipoic acid – mg/d Coenzyme Q-10 = 300 mg/d Magnesium oxide = 500 mg/d Omega-3 fish oils = 3-4 gm/d Vitamin B2 (riboflavin) – mg/d Property of Sheltering Arms. Do not alter, copy or use without permission

Somatic Symptoms DIZZINESS Dysfunction of the vestibular system
as many as 80% independent risk factor for failure to return to work Correlation with other post-concussive sx: PTH, may contribute to dizziness  manage HA, + VT Anxiety: esp visual vertigo = space & motion discomfort  anxiolytic + VT, more research needed Anxiolytic is a drug used to decrease anxiety Property of Sheltering Arms. Do not alter, copy or use without permission

Sleep Cycle Dysregulation Sleep cycle dysfunction
Trouble falling asleep Too much/little sleep Fragmented sleep Somatic Symptoms Headache Dizziness/ balance Nausea Light /noise sensitivity Tired, low energy Blurred vision Cognitive symptoms Concentration Memory Fogginess Cognitive fatigue/slowing Mood Disruption Irritability Sadness Anxiety/nervousness Emotional lability Property of Sheltering Arms. Do not alter, copy or use without permission

Sleep Cycle Dysregulation
Etiology in TBI Anxiety-depression Environmental – stimuli from music, phone, tv etc Neurophysiologic injury Pain Pharmacologic effects h/o sleep disorder Property of Sheltering Arms. Do not alter, copy or use without permission

Adverse Effects ↓ QOL ↑risk of accidents ↑rate of chronic pain Difficulty concentrating Mood changes Independent risk factor for poor physical and mental health (Walsh JK, J Clin Psychiatry 2004) Property of Sheltering Arms. Do not alter, copy or use without permission

TREATMENT Nonpharmacologic Pharmacologic Property of Sheltering Arms. Do not alter, copy or use without permission

Nonpharmacologic Rx Proper sleep hygiene no electronics (TV, computer, phone, music) at bedtime avoid caffeine, EtOH, nicotine 4-6 hrs before bedtime consistent bedtime & wake-up schedule no daytime naps sleep restriction 7-9 hrs Relaxation tx Property of Sheltering Arms. Do not alter, copy or use without permission

Pharmacologic Rx Melatonin : 3-5 mg Anti-depressants Amitriptyline : titrate, 30 mg Trazodone : 100 mg Non- benzodiazepine hypnotics – short term x 1 week, to reset cycle Zolpidem (Ambien) 5-10 mg, 12.5 mg XR Ezopiclone (Lunesta) 2-3 mg Zaleplon (Sonata) mg Anti-histamines Hydroxyzine (Vistaril ): Kids mg, adults mg - Benzodiazepines : caution Property of Sheltering Arms. Do not alter, copy or use without permission

Cognitive Symptoms Sleep cycle dysfunction Trouble falling asleep Too much/little sleep Fragmented sleep Somatic Symptoms Headache Dizziness/ balance Nausea Light /noise sensitivity Tired, low energy Blurred vision Cognitive symptoms Concentration Memory Fogginess Cognitive fatigue/slowing Mood Disruption Irritability Sadness Anxiety/nervousness Emotional lability Property of Sheltering Arms. Do not alter, copy or use without permission

Cognitive Symptoms Neurocognitive testing → objective data utilizing reliable & valid tests Moderate to severe TBI, cognitive deficits improve with neurostimulants In postconcussion syndrome No RCT Anecdotal reports of benefit More widely used Property of Sheltering Arms. Do not alter, copy or use without permission

Cognitive Symptoms Pharmacologic Rx
Amantadine : 100 mg BID Methylphenidate : mg/day, divided 2-3 x/day Atomoxetine : 40 mg/day Modafinil: /day Speech Tx: learning compensatory strategies Property of Sheltering Arms. Do not alter, copy or use without permission

Mood Disruption Sleep cycle dysfunction Trouble falling asleep Too much/little sleep Fragmented sleep Somatic Symptoms Headache Dizziness/ balance Nausea Light /noise sensitivity Tired, low energy Blurred vision Cognitive symptoms Concentration Memory Fogginess Cognitive fatigue/slowing Mood Disruption Irritability Sadness Anxiety/nervousness Emotional lability Property of Sheltering Arms. Do not alter, copy or use without permission

Mood Disruption Emotional disturbances
frustration, anxiety - from prolonged cognitive, somatic and sleep-related symptoms isolation - cognitive & physical rest, limitations on activities (school, work, athletics) PTSD Worsen perception of cognitive impairment and pain Interfere with recovery Rx: Medical psychologist &/or psychiatrist referral SSRI, TCA no RCTs in concussion treatment caution in adolescents: suicide risk Property of Sheltering Arms. Do not alter, copy or use without permission

Psychology management/Return to Learn
Concussion Psychology management/Return to Learn

Concussion Management: Clinical Psych/Neuropsych
Assessment Academic Accommodations Management of complex persistent symptoms Guidelines for return-to-learn Property of Sheltering Arms. Do not alter, copy or use without permission

Initial Assessment Computer-administration of Neurocognitive Screening (e.g., ImPACT, CNS Vital Systems, etc.) Diagnostic clinical interview Targeted questions regarding symptom onset, duration, severity, and factors that exacerbate, maintain, and alleviate symptoms. Detailed history: medical, psychosocial, education/intellectual Functional impact of symptoms (e.g., Now I can’t do _____ because of ______); how symptoms manifest in daily living. Property of Sheltering Arms. Do not alter, copy or use without permission

Initial Assessment Results (Briefly review and interpret along with reported symptoms, timelines, literature, etc.) Feedback with EDUCATION and EXPECTATIONS Discuss some of the findings, normalize, provide clear expectations to reduce unnecessary stress/catastrophizing. Variability is normal… Property of Sheltering Arms. Do not alter, copy or use without permission

Additional Assessment
Additional measures (when necessary?) When a patient is reporting symptoms beyond a typical recovery window for their age/demographic, and symptoms are of clinical significance such that they impede functioning/daily activities. When a patient’s performance on neurocognitive screening measures is significantly below the norm. In this circumstance, a detailed patient history should have already been obtained. A thorough review of academic records may be necessary including previous psych or neuropsych testing (don’t assume a patient, or their parents will disclose this upon initial interview…) Based on the subjective difficulties, reported symptoms, and performance on screening measures, a patient may require more extensive psych or neuropsych testing. A targeted battery is often sufficient when a detailed history including records are available. For many cases, however, a comprehensive neuropsych battery may be necessary to provide more thorough and accurate information regarding the patient’s current level of functioning as well as some estimates of pre-injury abilities. (see Kirkwood & Yeates, 2012 for a full list of psych and neuropsych measures with detailed table to illustrate when most/least appropriate for administration). Property of Sheltering Arms. Do not alter, copy or use without permission

Academic Accommodations
Common Accommodations: Proactive Rest, Reduced work (prioritized and structured plan when necessary); Tinted lenses; reduced computer time; structured reading breaks Factors to consider: Deficits, Symptoms, Healing/recovery curve, catch-up work, additional stressors. a typical student/patient will recover to a level for full academic participation without accommodations within two to four weeks (citation) with this time increasing for younger students. However, when he/she return to this full capacity, it can be anticipated that he/she will have missed a substantial amount of academic material. This is why it is so important for early identification, involvement of multidisciplinary professions, and communication/collaboration between the school and the treating clinician. Accommodations often are necessary beyond the typical recovery window to allow time for the student to make up missed work and to develop a plan to reduce nonessential workload to reduce likelihood of the student becoming overwhelmed with make-up assignments. (Stress often primary underlying factor of prolonged recovery/persistent symptoms – McCrea, 2008). Property of Sheltering Arms. Do not alter, copy or use without permission

Management of Complex Persistent Symptoms
Referrals and collaboration: Involvement of other physicians/professionals as necessary (e.g., PM&R, Neurologist, Ophthalmologist, Physical Therapist, Psychiatrist, School Psychologist, Social Worker, Case Manager, etc.). With or without a documented remarkable psychological/psychiatric history, individuals who have sustained a concussion and continue to experience problematic symptoms can benefit from psychologically-based interventions. Stress reduces the brain’s capacities to heal. Stress can impact sleep hygiene, appetite, and general self-care which can all impact the duration of symptom resolution. Property of Sheltering Arms. Do not alter, copy or use without permission

Management of Persistent Symptoms
Stress Reduction/Coping Skill Training Diaphragmatic Breathing Progressive Muscle Relaxation Compensatory Strategy Training (using a notebook and/or calendar, adding structure to support prioritization and recommended limitations e.g., proactive rest). Mindfulness-based interventions (e.g., meditation) Students/patients often do not know what to do during their “rest time” within a schedule of proactive rest. I typically obtain some of this information during the interview (activities, interests) and encourage them to utilize what has worked in the past if they can identify anything (e.g., listening to music). For many, social activity and sports are primary means of coping and no longer adaptive through recover, so they need to learn something else as explained above. For patients that I see over a span of 3-6 weeks, I will typically schedule 1-3 sessions specifically for this type of therapy/skill building. For other’s who need more intensive and comprehensive psychotherapy, they will receive this recommendation and either start with me (depending on age and availability) or be referred to one of our colleagues in the community. Property of Sheltering Arms. Do not alter, copy or use without permission

Guidelines for Return-to-Learn
Rest is crucial in first few days; return to cognitive activity has been gaining attention as prolonged rest can be counterproductive. (see Kirkwood, 2012, McCrea, AACN 2014, Iverson – 2014). Structured return-to-learn is typically advisable within one to two weeks of the injury… Homebound education – conservatively recommended with caution…can be helpful for select cases. Not only does lack of cognitive activity pose possible additional challenges to recovery; time away from school typically corresponds to pile-up of work and additional stress which definitely does not help recovery. Homebound education can be helpful particularly for students with complex history, complex presentation of current difficulties, and persistence of moderate to severe symptoms significantly beyond expectations per review of the literature. Property of Sheltering Arms. Do not alter, copy or use without permission

Neurocognitive Testing
Neurocognitive screenings (both computerized and paper versions) were developed out of a need to better way to assess impairments as related to concussion and to assist with diagnosis. Studies also suggest that up to 50% of athletes experience concussion symptoms per year, but only 10% report having an injury. Some examples of computer-based neurocognitive testing are; Cogsport, Headminders (CRI), ANAM, Concussion Vital Signs ImPACT. *It is also recommended and helpful to be able to make academic accommodations based on the findings of this testing to help the patients better manage school environments successfully.

Neurocognitive Testing
Studies have looked at the sensitivity of using balance testing, a symptom checklist and neurocognitive testing individually in detecting concussion; they were 62%, 68% and 79%. Used together, their sensitivity was determined to be 90% (Broglio SP M. S., 2007). Resolution of hyperactivity on functional MRI correlates with recovery on ImPACT (Lovell MR, 2007). When computerized neurocognitive testing is utilized, athletes are less likely to return to play within a week, compared to those with whom it was not utilized – 13.6% vs. 32.9% (Meehan W., 2010). **Take home – Just one of the many tools that should be used.**

ImPACT Computerized neurocognitive screen
Baseline Testing recommended every 2 years Assesses the following: Symptoms with a checklist Attention span Working memory Sustained and selective response time Response variability Non-verbal problem solving Reaction time

Physical therapy management
Concussion Physical therapy management

Vestibular and oculomotor impairments
Concussion Vestibular and oculomotor impairments

Impairments Oculomotor Dysfunction Vestibular Impairments
Balance Impairments Cervical Impairments Autonomic dysfunction/ physiologic impairments These are the impairments that are most often seen on PT evaluation. Often we find that the symptom report of blurry vision or increased dizziness is directly related to the inefficient movements of the eyes after concussion. In addition the discoordination between the eye and head movements would cause an increase in dizziness and made more stimulating and busy environments extremely symptom provoking and difficult to navigate. Secondary to these issues being identified early on in concussion is a newer development finding research to support particular interventions was challenging that were not more focused on retrospective chart reviews. More and more evidence is coming out all the time the following is a sample of what is available and what was used to create the CPG and guide treatment for our program.

Physical Therapy Intervention
Concussion therapy is focused on symptom reporting and targeting interventions to noted impairments. Heavy emphasis on the vestibular system and c-spine Physical therapists are uniquely qualified to help manage and treat this population: Vestibular therapy Manual therapy for cervical impairments Exertional therapy for return to activity/play with continued emphasis on testing the vestibular system -Physical Therapists are specialized in the rehabilitation process and effective in managing the scope of symptoms and concerns as they relate to recovery. -The practice domains listed above are the areas in which PTs can intervene with this population. -Recent research has seen the benefits of physical therapy intervention related to identification, treatment and symptom management of concussion – in particular impairments with the vestibular system. Multiple studies have found intervention affective in treating impairments related to concussion. Specifically, in a study by Alsalaheen in 2010, vestibular therapy was assessed through a retrospective chart review: (67 </= 18 years; 47 >18 years of age) Looked at outcome measures of self-report (dizziness severity, ABC Scale, & DHI in addition to Gait & balance measures ( DGI, gait speed and SOT). -Improvements were observed in all self report, gait & balance performance measures at time of d/c. Retrospective chart review of 114 pts Results: Median length of time between concussion and initial evaluation was 61 days. Conclusion: Vestibular Rehabilitation should be considered in the management of individuals post concussion who have dizziness and gait and balance dysfunction that do not resolve with rest. (Alsalaheen, 2010) CLINICAL QUESTION AT HAND: how do we best manage this population and take all of the developing research and existing information that is available to treat concussion? -Our program is PT led with PT serving as the gate keeper to other concussion based services. (1) support of the research for PT to address impairments and symptoms related to concussion (2) speed of which we could have patients come in for evaluation. -This placed a lot of responsibility at the same time on the PT to be able to differentially diagnose the patient’s impairments as well as be aware of any and all of the red flags that warrant a referral. -Based on this it became clear that there needed to be a team approach and a network of referral resources to most effectively manage this population. -Since the development of the CPG, which is currently undergoing revision based on new evidence: the program has changed over the last year, with still the same premise, however recognizing the significant impact of medical psychology with stress management and academic accommodations we knew that they needed to be on the forefront as well. The next part of the presentation will focus on the development and role of the CPG for PT intervention, and then our medical psychologist will talk more about his continued developing role in our program. Property of Sheltering Arms. Do not alter, copy or use without permission

PT Evaluation Detailed history Strength/ROM Oculomotor exam
Vestibular testing Balance Gait Education on concussion symptoms and activity modifications -Additionally, ImPact testing is performed if the patient is not scheduled to see our Medical Psychologist that day Property of Sheltering Arms. Do not alter, copy or use without permission

Evaluation – Red Flags REFER TO NEUROLOGY IF YOU SEE ANY OF THE BELOW AS A NEW SYMPTOM: * visual field cuts * hyper/hypo deviations with cover/uncover test * dysconjugate eye movements * significant memory loss – persistent * significant one sided weakness * seizures – new onset REFER TO ENT FOR: * one sided hearing loss or significant ringing or aural symptoms -This slide covers the red flags mentioned earlier that we as PTs screen for during our initial evaluation. -We are able to work with our PM&R MD to facilitate referrals to these specialists directly or once she has seen them for a visit. Property of Sheltering Arms. Do not alter, copy or use without permission

Evaluation – Red Flags REFER TO ORTHO OR NEED FOR FURTHER WORK UP:
* for persistent neck complaints and/or report of numbness or tingling REFER TO PM&R FOR BELOW: * significant difficulty with sleep regulation * persistent headaches * significant difficulty with concentration * guidance with school and/or work accommodations * when issues are not resolving with PT for further recommendations or specialist referrals -Of these providers, we are most frequently encountering patients who require referral to our Physical Medicine and Rehab MD upon initial evaluation. Property of Sheltering Arms. Do not alter, copy or use without permission

PT (cont)… Exertional/Return to play Testing vs Rehab
Graded exertional return to sport/activity 5 stages; including aerobic, strength, stretching and dynamic exercises Include head/body position changes to test the vestibular system Include balance and dual tasking as needed When symptom free RTP decisions; collaborative effort Clear for activity If symptomatic Symptom exacerbation Establish thresholds -At the conclusion of our initial evaluation, we have also determined if the patient is appropriate to advance to return to play with the initiation of exertion based testing, or will require intensive vestibular rehabilitation first -Depending on the patient’s length of time since injury and degree of symptoms, it may be appropriate for exertional testing to be performed to assess for exercise tolerance even if the patient is not yet symptom free. -Will go into further details regarding the specifics of our RTP protocol in upcoming slides Property of Sheltering Arms. Do not alter, copy or use without permission

Evaluation – Subjective
There are four key areas to investigate in the subjective portion of the therapist’s evaluation: (1) mechanism of injury (2) symptom reporting and management (3) past medical history (4) pain Mechanism of Injury Use of the clinical history specific questions to obtain this information. -It is important to note the mechanism to determine what type of forces the brain may have gone under, as well as if the patient was able to brace for impact or not. -Two components of acceleration that occur in nearly every instance of concussion are linear and rotational acceleration -Due to the physical properties of the highly organized brain, brain tissue deforms more readily in response to shear forces compared with other biologic tissues. -Rapid head rotation generates shear forces throughout the brain, resulting in a high potential to cause shear induced tissue damage leading to concussive symptoms -If head motion is constrained and there is no rotation it is difficult to produce traumatic unconsciousness. -Allowing a rotational acceleration greatly increases the chance of unconsciousness, resulting in more significant injury. (Meaney D, Smith D. Clin Sports Med 2011) Further, as mentioned earlier, symptoms at the time of injury are also clinically useful for prognostic indications: -Dizziness at the time of injury was found to be 7x more likely to predict a protracted recovery (>21 days as previously defined) Property of Sheltering Arms. Do not alter, copy or use without permission

Evaluation - PMH Considerations: Research has shown that there are certain things in a patient’s PMH that can affect overall recovery and indicate a risk for prolonged recovery. The most pertinent factors at this time : previous history of concussion, personal or family history of migraine personal or family history of visual impairments personal or family history of anxiety and/or mood disorders personal and or family history of learning disabilities or ADHD. Clinical history questionnaire The above factors have all been found to have potential to affect the patient’s length of recovery. -Visual impairments include previous eye alignment dysfunction or impairment, even as a young child. -A patient with a history of anxiety/mood disorder often flags the therapist to recognize the need for early medical psychology intervention as this is often augmented post-concussion. -In a study conducted by Iverson, Collins et al in 2003 showed that there was beginning evidence to suggest that there was a cumulative effect on cognition after multiple concussions in amateur athletes. However, another study that was published in the Journal of Neurosurgery in Oct 2012, concluded that Increasing recovery time between injuries improves cognitive outcome after repetitive mild concussive brain injuries in mice. -Additionally, there is conflicting evidence that reports whether a younger age has an effect on recovery: There have been studies that have found a longer recovery from concussion in high school athletes as compared to college athletes. However, in a study published in the Journal of Neurosurgery in 2013 compared recovery among college and HS athletes and found no significant difference between the two groups. **For our practice, it is important to be aware of overall age when deciding on outcome measures as well as overall need for academic accommodations and education of parents. -There have also been several studies that found that females were at greater risk for concussion as well as take longer to recover, however we use this information as a consideration in addition to all of our other non-modifiable PMH as described on this slide Property of Sheltering Arms. Do not alter, copy or use without permission

Evaluation: Symptom Reporting & Mgmt
Symptom Reporting and Management Clinical history with questions specific to concussion Rivermead Post Concussion Questionnaire** Dizziness Handicap Inventory Activities Balance Confidence Scale** Post Concussion Symptom Scale Neck Disability Index -Symptom reporting and management are critical throughout recovery -Subjective and difficult to track progress -Use questionnaires to track report and resolution -Acknowledge that no symptom of concussion is unique to concussion -ask specific questions and ask them to describe their symptoms to better understand the scope of the impairments as well as any previous history that could be contributing. Initially using the Rivermead Post Concussion Questionnaire and the ABC, with practice we found that the Post concussion symptom scale and the neck disability index were better tools and especially helped to guide treatment if there is cervical involvement. - Want to if they are experiencing any pain (aside from the headaches) now that they were not having before. - This can alert the clinician to any other possible injuries as well as any cervical involvement. - It is also important when discussing their headache to have them describe what the headache is like. - Headaches associated with concussion are very commonly described as a pressure in the head that gets worse as the day goes on as opposed to the pain more typically associated with a sinus headache or cervicogenic headache for example. Recommendations for Sheltering Arms: Clinical history questionnaire Pain scale/rating Supporting Evidence: In a study by Mihalik, Stump, Collins et al that was published in the Journal of Neurosurgery in May 2005, concluded that those that suffered headaches with migraine type characteristics after concussion were more likely to have prolonged recovery as well as more significant impairments as compared to those with just a headache or no headache at all. Property of Sheltering Arms. Do not alter, copy or use without permission

Evaluation – Objective Portion
The primary areas of focus in the objective portion of the concussion evaluation are: (1) strength/ROM (2) oculomotor screen (3) vestibular testing (4) balance testing/gait (5) neurocognitive screening/testing -Based on mechanism of injury it is necessary to screen cervical ROM and UE ROM for any signs of injury or impairment. With traumatic injury symptoms can be complicated and be a result of cervical injury or cervicogenic dizziness. It is not uncommon for patients to report neck pain from an injury that also results in a concussion. Supporting Evidence: Afferent activity in the neck participate in perceptual functions & reflex responses Injury results in abnormal proprioceptive information from cervical muscles that causes a mismatch between vestibular, visual and cervical inputs – resulting in a report of dizziness (Brandt 2001) -Neurocognitive screening/testing, namely ImPact, may be performed at PT visit, at visit with Medical Psychologist, or with both -Other 3 areas of testing will be covered on following slides Property of Sheltering Arms. Do not alter, copy or use without permission

Objective – Oculomotor Exam
Convergence/divergence smooth pursuits saccades gaze holding in 9 cardinal planes King Devick Test (assesses reading saccade function) (Dhawan, Starling, et al.) VOMS -We assess each of the items, determining if they appear to be WNL or abnormal, and for whether or not they result in symptom provocation -The King Devic test includes 3 cards displaying rows of numbers that become increasingly more difficult to read with each progressing card. The patient reads the numbers out loud on the cards and is timed for speed and checked for accuracy, which are the values that we look at to determine WNL vs abnormal. This test can be performed with physical cards or on an iPad. -In a study by Dhwawan, Starling, et al., (April 2014) the King Devic test was used to test high school hockey players to assess the effects of concussion in adolescents on long-term cognitive and visuospatial performance and determine if similar impairment (subclinical concussion) exists in athletes without obvious head injury. The athletes underwent K-D testing pre-season, post-season and immediately after suspected concussion. All were assessed pre- and post-season with a computerized cognitive assessment test (Axon Sports®). Results showed that the King-Devick testing accurately identifies real-time, symptomatic concussion in adolescents. Scores in concussed players may remain abnormal over time. The K-D test may additionally detect asymptomatic concussion. Clinically, we use this an another objective measure to detect oculomotor impairments especially when we see patients in the acute phase of recovery. Property of Sheltering Arms. Do not alter, copy or use without permission

Oculomotor Dysfunction
Ocular Motor Dysfunction following mTBI [blast-related] (Capo-Aponte et. Al Military Medicine 2012) -This chart is an example of some common oculomotor impairments that are seen after concussion. This particular group was from the military and related to blast concussion. -It is also important to note that any preexisting oculomotor impairments have the potential to decompensate and affect recovery after concussion. -The primary impairments that we focus on treating are saccades and smooth pursuits initially and if convergence continues to be an issue we will render treatment. *most often with the treatment of saccades and at times smooth pursuits, symptoms improve and the other impairments are not as much of a factor as well. Property of Sheltering Arms. Do not alter, copy or use without permission

Objective – Vestibular Exam
VOR x 1 viewing (active) first slow and then faster (in all 3 planes, Pitch, roll and yaw) Dix Hallpike if indicated (based on symptom reporting) Dynamic Visual Acuity Gaze Stabilization Motion Sensitivity Quotient (MSQ) -VOR x 1 training is the hallmark of our vestibular rehabilitation -Through clinical practice, we have found from retrospective chart review (n=17 – small sample) that normalization of VOR x 1 appears to correlate with symptom resolution -Testing for BPPV performed based on patient report of dizziness vs vertigo and triggering stimuli *<5% of patients under the age of 21 with concussion will have BPPV, however we include this in our array of testing as needed as the traumatic nature and the fact that we treat adults with concussion as well requires that it is included in our practice -MSQ has been determined to have good sensitivity and specificity for detecting motion-provoked dizziness. Patients reporting motion sensitivity following concussion should be assessed with the use of the MSQ to determine which position changes are symptom provoking. This then allows the clinician to develop clinical interventions and a home program to initiate habituation. It also allows an objective measure to track improvement with dizziness. (Akin et al. J Rehabilitation Research and Development. 2003) (Akin F.W., 2003) Property of Sheltering Arms. Do not alter, copy or use without permission

Vestibular Exam – Supporting Evidence
Studies found that impairments with gaze stability were present for as long as 4 weeks post concussion even with interventions. (Gottshall K, Drake A, Gray N, McDonald E, Hoffer ME. Objective vestibular tests as outcome measures in head injury patients. Laryngoscope. Oct 2003; 113(10): Another study found that there was evidence to support meaningful improvement in target following and DVA after 8 weeks of vestibular therapy and 12 weeks for gaze stabilization impairments (Gottshall, K. Hoffer, Michael. Tracking Recovery of Vestibular Function in Individuals with blast induced head trauma using Vestibular-Visual-Cognitive Interaction Tests. JNPT. June 2010) MSQ has been determined to have good sensitivity and specificity for detecting motion-provoked dizziness. Patients reporting motion sensitivity following concussion should be assessed with the use of the MSQ to determine which position changes are symptom provoking. (Akin et al. J Rehabilitation Research and Development. 2003) (Akin F.W., 2003) This then allows the clinician to develop clinical interventions and a home program to initiate habituation. It also allows an objective measure to track improvement with dizziness.

Vestibular OcularMotor Screen
Clinical assessment used at time of initial evaluation as well as on re-evaluations/discharges as needed Symptoms measured at baseline and with testing: Headache Dizziness Nausea Fogginess Testing Smooth pursuit Saccades Convergence VOR x 1 Visual motion sensitivity (VOR cancellation) Mucha, A., Collins, M.W., Elbin, R.J., Furman, J.M., Troutman- Enseki, C., DeWolf, R.M., Marchetti, G., Kontos, A.P. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. American Journal of Sports Medicine October; (42) 10. -No controls reported a total symptom score greater than 2 after any VOMS individual item -research article describes a standardized fashion of performing testing -NPC > 5 or any VOMS item symptom score > or = to 2 resulted in an increase in the probability of correctly identifying concussed

Demonstration Video - 1

Demonstration Video - 2

Evidence-Based Practice: VOD
Vestibular-ocular dysfunction (VOD) in acute sports related concussion (SRC) and postconcussion syndrome (PCS) Postconcussion syndrome defined here as those with symptoms lasting > 1 month Findings: Median duration of symptoms Those with SRC and VOD: 40 days Those with SRC without VOD: 21 days Statistically significant increase in the adjusted odds of developing PCS among patients with acute SRC who had VOD than those without Ellis, M. J., Cordingley, D., Vis, S. Reimer, K., Leiter, J., and Russell, K. Vestibulo-ocular dysfunction in pediatric sports related concussion. Journal of Neurosurg Pediatrics. June 2015. -Testing for VOD performed by a single neurologist -In this study, patients did not receive standardized rehabilitation. Not all were referred for therapy services.

Vestibular Impairments
**Studies that have used the SOT to evaluate balance in collegiate athletes and military personnel have consistently demonstrated a primarily vestibular pattern of balance impairment on sensory analysis in contrast to vision or somatosensory based patterns** Dizziness second most common symptom complaint after concussion after headache Dizziness only on field symptom found to be an independent predictor of protracted recovery

Evidence-Based Practice: Objective Tests
Objective Testing of Children with Dizziness and Balance Complaints Following Sports Related concussions 42 pts – 25 girls and 17 boys Age range 8-18 – avg /- 2.4 years Testing included SOT, VNG, bithermal caloric test, sinusoidal harmonic rotation chair test, DVAT, cervical vestibular evoked myogenic potential (cVEMP) test and static subjective visual vertical test *all performed by an audiologist Avg time between initial concussion and vestibular testing 26 +/- 20 weeks Only 4% of the 42 pts had completely normal vestibular and balance test battery 55% underwent DVAT testing and of those 57% were abnormal; 40% who had SOT testing were abnormal 25% abnormal VNG Based on testing results – ***abnormal DVAT results seen in this study and in others may not reflect a direct injury to the peripheral vestibular system from concussion but may instead result from impairment of central integration of visual and vestibular stimuli at the central integration of visual and vestibular stimuli at the level of the brainstem or cerebellum***.

Objective – Balance Testing and Gait
Considerations: Balance deficits are often reported in the first week after injury and typically are one of the first things to recover. -For this population it is important to still examine balance; however with a focus on more detailed breakdown and looking at the vestibular and visual systems as they both relate to balance. -Studies have looked at the sensitivity of using balance testing, a symptom checklist and neurocognitive testing individually in detecting concussion; they were 62%, 68% and 79%. Used together their sensitivity was determined to be 90%. (Broglio, Macciochi, et al. 2007, Resch, May et al). Thus this demonstrates support for using a combination of these clinical tests to assess for the presence of concussion rather than one stand alone test. Property of Sheltering Arms. Do not alter, copy or use without permission

Balance Impairments 43% of athletes report balance dysfunction as an early symptom following sports related concussion (Lovell 2004) Postural Control assessment should be combined with other evaluative measures to gain the highest sensitivity to concussive injuries (Broglio, 2007) Balance dysfunction may resolve more quickly than other symptoms following concussion (Catena 2011) BESS test designed specifically for concussed athletes – accurate only within 1-3 days post injury (Broglio 2009, Peterson 2003) Tests we use: mCTSIB (Modified Clinical Test of Sensory Interaction on Balance) SLS – EO/EC BESS FGA Community Mobility and Balance Scale *see rehabmeasures.com for further information regarding these scales -Gusikiewicz, et al. demonstrated persistent impairments with postural sway with individuals with mTBI using the mCTSIB. (Guskiewicz , Perrin, et al. 1996) -FGA demonstrates acceptable reliability, internal consistency, and concurrent validity with other balance measures (DHI, ABC scale, TUG, DGI) used for patients with vestibular disorders. (Wrisley, 2004) *FGA and CM&B – are used as needed. We typically will use these with an older population or if we are trying to tease out impairments that are not clear with other testing. Property of Sheltering Arms. Do not alter, copy or use without permission

Cervical Impairments ROM Sensation Palpation Joint stability testing
Strength testing Manual therapy as indicated Cervical Proprioception testing and training

Cervicovestibular rehabilitation in sport-related concussion: a RCT
Persistent symptoms of dizziness, neck pain and/or headaches post sports-related concussion Control group: postural education, ROM, cognitive and physical rest until asymptomatic then RTP Intervention group: cervical spine and vestibular rehab Conclusion: intervention group was 3.91 times more likely to be medically cleared by 8 weeks -Age range: 12-30 -18 males, 13 females (31 total) -Persistent symptoms, defined as > 10 days from time of injury -1x/week sessions with PT for 8 weeks or until time of clearance – sports medicine MD blinded to groups provided clearance -Cervical spine interventions included: manual therapy for the cervical and thoracic spines (joint mobilization), therapeutic exercise consisting of cervical neuromotor retraining exercises (craniovertebral flexor and extensor retraining) and sensorimotor retraining exercises. -Vestibular rehabilitation: habituation, gaze stabilization, adaptation exercises, standing balance exercises, dynamic balance, and canolith repositioning maneuvers

Physiologic/Autonomic Dysfunction: When can I exercise?
Research has shown that the Balke Treadmill protocol has been an effective tool to help identify symptom reproduction in post concussion syndrome. It has also been rated for reliability for accurately reproducing maximal heart rate and systolic blood pressure of symptom reproduction in those with PCS. Based on these findings it is useful to determine sub symptom threshold exercise prescription for those that are still experiencing symptoms as well as determining readiness to initiate the return to play/activity protocol. (Leddy et al. Clin J Sport Med. 2011)

Evidence-Based Practice: Physiological Markers
Some patients with PCS have difficulty tolerating return to exercise May have inability to pass exertional testing due to symptom onset Found to be a result of altered cerebral blood flow (CBF) regulation due to reduced CO2 sensitivity Hypothesized to then cause symptoms of headache and dizziness at threshold intensity Utilization of a progressive subthreshold exercise program Increased CO2 sensitivity to near normal levels Improved exercise tolerance with ability to exercise to exhaustion without symptom onset Suggests that “return of normal control of exercise CBF and of exercise tolerance could be objective physiological markers of recovery for concussion, which has implications for establishing prognosis and preventing premature return to sport, activity, or military duty -protocol: exercised 20 minutes/day, 5 to 6 days/week, at an intensity of 80% max HR achieved during the first treadmill test

Exercise Another study that looked at sub symptom threshold exercise prescription for treatment of post concussion syndrome concluded that overall those who participated in the exercise rehabilitation program returned to full daily functioning. (Baker et al. Rehabilitation Research and Practice. 2012)

Concussion Examples of treatment

Return to play protocols
Concussion Return to play protocols

Return to Play/Activity
Symptom management continues even with RTP Returning an athlete to play prior to full resolution of the concussion can have negative effects Research has shown that student athletes who have engaged in high levels of activity in the weeks following a concussion had increased symptoms, worsened neurocognitive data, and significantly longer recovery times (Majerske et al. J of Athletic Training 2008) Before any patient is cleared for RTP, he/she must be symptom free with multiple stipulations & a clear vestibular examination

Return to Play/Activity
The Return to Play protocol 5 stages, Largely based on the protocol that is being used by University of Pittsburgh Medical Center Guidelines recommended by The 4th International Conference on Concussion In Sport. The protocol requires a graduated increase in demand of HR (max exertion formula) and exertion (perceived exertion scale) Largely focused on: Increasing demands of head/body position changes balance and vestibular challenges dual tasking and sport specific movements All used to ensure that the athlete/patient is ready to return to all previous levels of activity without concern for symptom exacerbation

Return to Play Criteria
Symptom free at rest Clear oculomotor/Vestibular and balance exam Symptom free with cognitive/physical exertion Full day/schedule/load at school Off medications* * Normal neurocognitive data – both baseline and post exertion for optimal clearance* * ~30% of athletes who were back to baseline on ImPACT and reported no symptoms at rest failed a post exertion ImPACT test in spite of reporting no symptoms after exertion (McGrath et al,Brain Injury: 2013) ** exceptions with a prolonged recovery and will require pt repeat stages if still on medications – final clearance by MD if still on medications

RTP: Exertion Therapy Post Concussion
Patients should be symptom free for 24 hours prior to progressing to the next stage (cannot complete two stages in one day). If the patient reports symptoms during any stage, terminate the activity; allow the patient to recover and rest until symptom free. The next session should return the patient to the same stage and then repeat. If patient presents with baseline symptoms: ensure those symptoms remain at the same level throughout the session complete each stage 3 times with same report before progressing to the next stage.

Sport Specific Return to Play Guidelines
Developed by Children’s Healthcare of Atlanta Based on the 7 stage RTP developed at the ICCS Football, gymnastics, cheerleading, wrestling, soccer, basketball, lacrosse, baseball, softball, and ice hockey Added a moderate activity step highlighted by resistance training Included non-contact and light contact in a sport specific fashion (May, Marshall, Burns, et al.) -Weight training can increase intracranial pressure and exacerbate post concussive symptoms. Low weight/high repetition recommended. -This information supports the structure of the 5 stage, UPMC based RTP protocol that we use as our standard. It is important that we include resistance based -training as well as sport specific exercises in our stages 3 & 4 since the demands vary by sport and just performing exertion based activities for RTP is inadequate to truly test the vestibular system and the athlete’s tolerance to the demands of their sport. -May, Marshall, Burns, et al. Pediatric Sports Specific Return to Play Guidelines Following Concussion. International Journal of Sports Physical Therapy. April 2014; 9(2):

Concussion Case studies

Patient Demographic Information
24 year old female Working in a church daycare center Reported LOC PMH: Migraine (single episode) Night terrors Depression (while in high school) 1 prior concussion 2-3 years previous which took 2 weeks to heal per the patient’s report Social Hx: College student PM&R physician pulled her from summer school -Reviewing her PMH, we find that she has several factors which could influence the length of her recovery, including history of previous concussion, history of depression, and history of migraine (even though it was a single episode; she may be predisposed to onset of post traumatic migraine with this history). Property of Sheltering Arms. Do not alter, copy or use without permission

Initial PT Evaluation Initial Evaluation took place 20 days after concussion Subjective MVA: rear-ended Post Concussion Symptom Scale: 108 – High Dizziness Handicap Index: 78 – severe handicap Objective ROM: full UE ROM, limited cervical extension Oculomotor Vestibular HEP: initial exercises for habituation Referrals generated to PM&R and Medical Psychology at this time -Mechanism of Injury: Reports going forwards, to the side, and then forwards again at the time of impact -Symptoms at the time of injury: positive LOC, 2-3 minute blackout, headache, dizziness, fogginess -Taken to the ER and had CT scan which was negative -Reported continued headaches, light and noise sensitivity, dizziness, feeling mentally foggy, difficulty falling asleep -Not working, not doing much else but reports still using TV/technology often Oculomotor exam: -abnormal smooth pursuits & symptomatic -abnormal saccades – overshooting & symptomatic -abnormal convergence & symptomatic -gaze holding WNL but symptomatic -unable to complete King Devic test at IE Vestibular exam: active VOR x 1 performed in sitting at self selected speed (patient using scale of 0= no dizziness, 5 = room spinning to subjectively rate her degree of dizziness) -horizontal x 16 reps – 2/5 dizziness -vertical x 13 reps – 3/5 dizziness -lateral tilting x 24 reps – 3/5 dizziness Property of Sheltering Arms. Do not alter, copy or use without permission

PM&R Management Posttraumatic headache Sleep dysregulation
Mood disorder Continue outpatient physical therapy Continue cognitive rest, minimizing TV and computer use. PCS scale score 6/10/14 initial = 64/132 6/24/14 = 48/132 7/22/14 = 23/132 8/19/14 = 5/132 (mostly mild symptoms of fatigue, low energy, fogginess and sleep changes, though sleep issue now related to job as bartender and np longer due to PCS) For posttraumatic headache – stopped hydrocodone. Prescribed Ibuprofen 600 mg prn – effective For sleep dysregulation – prescribed sonata 5 to 10 mg nightly as needed – effective For mood disorder – prescribed Zoloft, continue with supportive counseling & psychotherapy with Dr. Melchiorre – effective OPPT Letter written to VCU registrar because the patient enrolled in summer semester but unable to/not cleared due to PCS.

Medical Psychology Management
Presenting concerns/problems Mood disruption Cognitive symptoms Sleep cycle dysfunction Relevant past medical history Treatment Supportive Psychotherapy CBT – Behavioral Activation CBT – systematic desensitization CBT – sleep hygiene/behavioral modification Mindfulness-based interventions (guided meditation) -Presenting problems Fatigue Disrupted sleep Irritability Anxiety (both trauma-specific and increased general/hyperarousal) Disrupted appetite Headache (exacerbated by stress) Emotional dysregulation Mood decline -PMH Sleep dysfunction Sleep Terror Disorder (suspected) Nightmare Disorder (suspected) Major Depressive Disorder, Single Episode Migraine Headaches

Physical Therapy Management
Interventions and course of care: Balance testing Oculomotor training Habituation and adaptation based training Vestibular training Therapeutic exercise Return to Play protocol -mCTSIB WNL, L LE EC SLS was abnormal -Oculomotor emphasized saccades -Habituation and adaptation included otolith stimulation, figure 8 walking, repeated movement trials -Vestibular training including VOR x 1 progression and VOR x 2, walking with head turns, incorporating dynamic balance with multi-tasking (serial 7’s) -Therapeutic exercises: recumbent cycling, Balke treadmill protocol Balke treadmill protocol cleared on 7th visit - *performed as soon as possible for stress management, VOR x 1 was cleared on the 11th visit Completed RTP protocol to stage III and was to follow up with PT in 2 weeks if symptoms returned. At that time was only having problems with sleep and emotional regulation and was managed by PM&R MD for that; and was discharged from all disciplines with noted full recovery to baseline Property of Sheltering Arms. Do not alter, copy or use without permission

Case study #2 15 year old female
Competitive cheerleader, participates year round as a level 3 competitor Presented to PT about a week after she noticed symptoms including headache and dizziness Subjective: No one incident caused her concussion, reported that she “was elbowed in the nose a cajillion times a day in practice.” Noticed a week ago that “words were moving around” when she was trying to read for school PMH: Family history of migraines Personal history anxiety No previous concussions

Case study #2 Objective findings:
Smooth pursuit: abnormal – 3/5 dizziness Saccades: abnormal – slight dizziness Convergence: WNL but with slight increase in dizziness Active VOR x 1 in sitting, tested at self selected pace: 5/5 dizziness in all planes, reps performed Abnormal SLS balance with EC on L LE with fall

Case study #2 20 visits over the course of 6 months to complete plan of care with full symptom resolution Patient followed by PM&R MD for medication management Final clearance for RTP provided by MD Interventions incorporated VOR x 1 training, habituation (Cawthorne Cooksey/repeated movements), saccades/compensatory saccades, otolith stimulation, use of technologies (iPad/wii fit),

Case study #3 14 year old male
Football player, does track in the spring Presented to PT 4 days post concussion – dizziness, headache, and noise sensitivity at the time of injury Second concussion in 3 months Following his first concussion he was out of play x 3 weeks Most recent concussion was hit x 2 in the same game with onset of dizziness and headache PMH Positive history of migraines Previous concussion: 1 in elementary school, one in July 2013 and current in October 2013

Case Study 1: PMH and Injury Information
13 year old male with onset of concussive symptoms after riding roller coasters at King’s Dominion in August 2015 Two episodes of blacking out on coasters with subsequent dizziness, headache History of concussion in February 2015 when he was checked in an ice hockey game Approximately 3 week recovery for full return to school Familial history of strabismus – both parents

Initial Evaluation Questionnaires: VOMS:
PCSS: 61 DHI: 78 VOMS: Abnormal smooth pursuit, saccades, convergence Abnormal VOR x 1 viewing and VMS Symptom increase across all areas of testing Decreased cervical ROM with increased turgor/pain with lateral flexion HEP given for smooth pursuit, saccades, and compensatory saccades -undershooting with saccades, convergence was 28 cm -tender to palpation especially with upper traps

Follow up visits Motion Sensitivity Quotient testing revealed L BPPV (posterior canal) Performed Epley to correct and educated on activity modifications Next session – no spinning – felt much better Continued to advance over the course of visits with intervention focused on oculomotor, vestibular, and manual therapy intervention -responded well to manual therapy to improve headaches -his headaches were typically provoked with longer duration reading and cognitive exertion -emphasis on turns and rotation once advancing to higher level vestibular intervention

The numbers 7 days from injury to initial evaluation with initiation of vestibular rehab 28 days from initiation of vestibular rehab to clearance with RTP recommendation 35 days from date of injury Final outcomes: DHI: 0 PCSS: 1 11 visits total from 8/26/15 to 10/7/15 -patient to follow up with MD for final clearance -patient chose to defer hockey this season and intends to return to training for track season once cleared

Summary Concussion & PCS are disabling conditions in the general population and athletes alike Individualized approach to treatment Interdisciplinary management is necessary – PT plays a large role in rehabilitation! Research is ongoing across all areas of management and changing daily Property of Sheltering Arms. Do not alter, copy or use without permission

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CONCUSSION: The Good the Bad, and the Ugly Cristin Bealzey, PT, DPT, CBIS Sheltering Arms – Total Concussion Care.

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CONCUSSION: The Good the Bad, and the Ugly Cristin Bealzey, PT, DPT, CBIS Sheltering Arms – Total Concussion Care.

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