1. Concussion Management

2. Steven Novakowski NCCP Certified Coach, 2011
Bachelor of Kinesiology; Pedagogy and Coaching, University of Calgary, 2013
Master’s of Science, Physical Therapy, University of Alberta, 2015
SHIFT Concussion, Certified Management Provider, 2015
Physical Therapist, Kinesis Physical Therapy, 2015-Present
Grande Prairie Storm Jr. A, Concussion Management Provider, 2015-present
R2P Concussion Management, Certified Provider
Grande Prairie Regional College Athletics Concussion Management Provider 2016-present
Grande Prairie Driller’s Sr. Football, Head Trainer, present
Grande Prairie Athletics Sr. Men’s AA Hockey, Head Trainer; 2016-present

3. Have you sustained A concussion?

4. Why concussion care? All different scenarios, all concussions.
1st Concussion
2nd Concussion
3rd Concussion
4th Concussion
Age 6
Monkey Bars
LOC
Mild Amnesia
Age 12
Football
LOC
++ Headaches
Age 16
Snowboarding
Terrain Park
LOC
Dizzy Spells
Headaches
Age 23
Snowboarding
Stationary fall
No LOC
Dizzy Spells
Headaches
Feeling “off”
Plus Multiple other bumps, hits, falls, etc. True number? Unknown
All different scenarios, all concussions.
Number of times diagnosed: 0

5. A Concussion is a Brain Injury.
What is a concussion?
A Concussion is a Brain Injury.

6. What is a Concussion?
A concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with a force transmitted to the head.
A concussion typically results in the rapid onset of short lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.

7. What is a concussion?
A concussion may result in neuropathological changes, but symptoms largely reflect a functional disturbance rather than a structural injury. Often there is no abnormality seen in x-rays, CT scan, or other imaging.
A concussion results in a variety of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.
Loss of equilibrium.

9. How do concussions happen?

10. Recognizing concussions
Jackson is in grade 6 and is standing near the soccer field at recess, when stray ball unexpectedly hits him in the back of the head. When checking on him, he does not have any issues. Later in the day, he complains of a headache and mild nausea. Does Jackson have a concussion?

11. Recognizing concussions
SCAT3
Sport Concussion Assessment Tool (3rd Edition)
SCAT 4 coming soon!
Page 2, most useful:
Symptom Score
Orientation
Cognition
Balance
Coordination

16. In implementing the SCAT3, perfection is NOT NEEDED!
Take the principles and apply accordingly!
Glasgow Coma Scale
Maddocks Score
Symptoms
Cognitive assessment: Orientation, Words, Numbers
Neck
Balance and Coordination

17. The result of a concussion? EVERGY CRISIS!

18. Energy Crisis Increased energy demands of the body.
Reduced relative availability of energy for other processes
All ethical debates aside, without the brain, life cannot be sustained.
When injured, the brain will command a greater percentage of total available energy to promote healing.
Energy demands of the body remain the same, but there is less available than prior to any incident.
The body essentially starves itself, performing vital functions at the expense of other systems.

20. Energy Crisis
Imagine reducing your food intake by 20 percent, then 1-2 percent PER DAY and continuing on with your day to day life.
Fatigue
Headache
Mood Changes
Irritability
Depression

22. Symptoms
The suspected diagnosis of concussion can include one or more of the following symptoms:
Headache, neck pain
Dizziness, vertigo, ringing in the ears
Light sensitivity, blurred or double vision
Fatigue, trouble falling asleep
Nausea and/or vomiting
Loss of consciousness, amnesia
Behavioral changes, such as irritability, depression, or mood swings
Cognitive impairment, including slowed reaction time and feeling “in a fog”

25. The international consensus treatment for a concussion is REST.
Facilitate Rest!
The international consensus treatment for a concussion is REST.
By achieving true REST, the demands on peripheral body systems are reduced, increasing the amount of energy available to heal the brain!

26. Quiz Number 1
Jackson is in grade 6 and is standing near the soccer field at recess, when stray ball unexpectedly hits him in the back of the head. When checking on him, he does not have any issues. Later in the day, he complains of a headache and mild nausea. Does Jackson have a concussion?

27. Facilitate Rest! Without alienating the child
Reduce the stress on peripheral body systems, especially ones requiring high levels of energy (i.e. vision, concentration).
Substitute or remove visual stimuli.
Avoid busy environments.
Coordinate stress reduction.
Tons of overlap

28. Facilitate Rest!
Without alienating the child
You send Jackson home with a possible concussion, the instruction being to rest.
NO cellphone, NO TV, NO friends, NO sports, NO computer, NO, NO, NO, NO!
How would you feel?

29. MAKE A plan for school
You can not keep a child home from school for too long for multiple reasons. A couple of days home is a good idea, but returning them to a familiar environment will likely help their mood.

30. 1. Substitute, remove, or reduce visual stimuli
Sitting at the front of the class to avoid distractions.
Note taking can be a nightmare.
Audio vs visual.

31. 2. Avoid busy environments
Providing the child with a quiet place to:
Rest or work quietly as needed. i.e. during group work, the whole group can work in a separate area.
Have lunch.
Take tests.
Allowing the child to arrive/leave early during transitions.
Physical Education.

32. 3. Coordinate stress reduction
Reducing work load.
Taking on a varied role in group projects.
Increased time to complete assignments.
Increased time to complete tests.
Allow the child to take breaks as needed.

33. Humans have been spontaneously recovering from concussions for as long as they have been getting hit in the head.
So why change things?

34. Graded approach to concussion Management
Exercise must be performed according to the FITT Principle: Frequency, Intensity, Time, Type.
We also know that exercise is medicine, we just need the correct type of exercise.
Physical vs cognitive exercise.

35. Complete concussion care

36. Complete concussion care
Evaluation and treatment of specific symptoms is a major deficiency in the process of managing concussions.
Research has determined that the best thing for the brain is rest, but there is more that can be done.
Clinically addressing dysfunction of individual body systems has been shown to improve long term outcomes for patients who have sustained a concussion.

37. Complete concussion care
Critical evaluation of each patient from a physical, neurological and cognitive perspective is important, and we treat according to best evidence.
Concussion treatment includes but is not limited to:
Education regarding energy conservation.
Vestibular and balance rehabilitation.
Visual and proprioceptive system retraining.
Management of concurrent injuries.

38. Graded approach to concussion Management
Student following CanChild and Parachute guidelines for Concussion Rehab:
Participate in physical activity as long as symptoms do not emerge.
If symptoms are provoked, rest.

39. The problem with Rest Dallas Bedrest Study 5 subjects in mid twenties
Tested VO2 Max, 1RM of multiple movements pre and post 30 days of bedrest.
Re-tested 30 years later.

40. Graded approach to concussion Management
Student participating in Kinesis Physical Therapy’s Concussion Management program:
Complete gradual exertional testing to determine level of participation in sport.
Participate for predetermined periods of time.

41. Quiz Number 1
Jackson is in grade 6 and is standing near the soccer field at recess, when stray ball unexpectedly hits him in the back of the head. When checking on him, he does not have any issues. Later in the day, he complains of a headache and mild nausea. Does Jackson have a concussion?

42. Quiz Number 1 Does Jackson have a concussion? Likely.
Does he have any other injuries?
Possibly.

43. Concurrent injuries Head Neck Back Shoulder Hip Knee Ankle Hand
All of the Above?

44. Home Exercise program (HEP)
Nobody is perfect. ALL PATIENTS receive a HEP. Patients are provided with a copy of their HEP and are taught how to implement it. I do my best to communicate. An invitation to contact me is ABSOLUTELY and open invitation. Use physical education time to perform home exercise program.

45. Home Exercise program (HEP)
Activities can include but are not limited to:
Neck stretching and postural retraining exercises.
Balance retraining.
Vestibulo-ocular reflex retraining**.
Exertional Testing; Bringing it all together.

46. Return to sport

47. Return to sport

48. Return to sport

49. Return to sport

50. Return to sport

55. Baseline testing ImPACT Testing Neurocognitive Assessment
Used in conjunction with other assessment methods and special tests.
Poor evidence, but something is better than nothing.
Best evidence is sometimes best available evidence.
Statistical vs Clinical Significance.
22 Symptoms
Rating Scale of 0-6

56. Concussion Symptoms Scale

58. 46 year old male
3 concussion sustained over the past year.
Works at a computer.
Headaches, irritability, emotional changes, dizziness, sensitivity to light and sound.

59. ImPACT testing Scores

60. 8 year old male
Concussion sustained skiing
Dizziness, Nausea, Neck pain, Depression, Emotional changes.
Mom states “He’s not the same kid anymore.”

61. 50 year old female
Car accident 4 months prior.
Received treatment for neck, back injuries.
Working full time, 90% of job is at a computer
Symptoms worsening over time; dizziness, feeling “off”, balance problems, headache, sensitivity to light and noise.

62. ImPACT testing Scores

63. But does it work? Baseline testing performed pre season.
Multiple concussions 2015/16 season
All resolved except 1.
That 1 was traded prior to completing his rehabilitation.
All returned to play.
No return of symptoms was noted.
Rehab vs. Motivation
Exertional testing performed to ensure safe return to play.
Coordinated with team trainer.

64. Key Points
A concussion is a brain injury and should be treated as such.
There is much more to concussion rehabilitation than just rest.
There are many opportunities for change in the school environment that can further facilitate recovery from a concussion.
Concussion rehab is exactly like rehabilitating any other injury, there is no set recipe!

65. 5th International Consensus Conference on Concussion Oct 2016, Berlin, germany

66. Thank YOU! Any Questions?