a little about me…. -...
TRANSCRIPT
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Evidenced Based Rehabilitation Strategies in Concussion
Management: A Clinical Trajectory Approach to Treatment for the
Physical Therapist
Becky Bliss, PT, DPT, NCS Diane Wrisley, PT, PhD
A Little About Me….
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Objectives
• Discuss the role of multimodal approach to concussion treatment based on driving clinical trajectories.
• Design impairment based treatment plans based on clinical trajectories to include vestibular/ocular, cervical and exertional components.
• Decide when to implement aerobic activity and begin the return to play activity prior to discharge from physical therapy.
• Identify patients that need referral to neuropsychology, neurology or possible neuro‐optometry for further assistance in post concussive management.
CB
Conceptual Framework…. UPMC
Concussion
Ocular
Post‐Traumatic Migraine
CognitiveFatigue
AnxietyMood
Cervical
Vestibular
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Ellis et al Brain Injury 2014
Cervical
CognitiveFatigue
Diagnostic Challenge
How is This All Related?
Journal of orthopedic & sports physical therapy | volume 47 | number 7 | july 2017 |
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SPORT-RELATED CONCUSSION: OPTIMIZING TREATMENT THROUGH EVIDENCE-INFORMED PRACTICE
Viewpoint
Sport-Related Concussion: Optimizing Treatment Through Evidence-Informed Practice
| VOLUME 46 | ISSUE 8 | August 2016 | © 2016 JOURNAL OF ORTHOPAEDIC & SPORTS PHYSICAL THERAPY®
Cervical Dysfunction and Treatment
Cervicovestibular rehabilitation in sport‐related concussion: a randomised controlled trialKathryn J Schneider1,2, Willem H Meeuwisse1,3, Alberto Nettel‐Aguirre2,3,4, Karen Barlow2, Lara Boyd5, Jian Kang1, Carolyn A Emery1,2,3
• Results In the treatment group, 73% (11/15) of the participants were medically cleared within 8 weeks of initiation of treatment, compared with 7% (1/14) in the control group. Using an intention to treat analysis, individuals in the treatment group were 3.91 (95% CI 1.34 to 11.34) times more likely to be medically cleared by 8 weeks.
• Conclusions A combination of cervical and vestibular physiotherapy decreased time to medical clearance to return to sport in youth and young adults with persistent symptoms of dizziness, neck pain and/or headaches following a sport‐related concussion.
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Joint Position Error Test
Cervical Proprioceptive Exercises
• Head Laser with Targets
• Combine with Saccades
• Eyes Closed awareness
• Add in Balance
• Reaction Time
Uppercervicalmanualdistraction,supine
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FlexionmobilizationO‐A
(extension mobilization at O‐A rarely indicated)
Unilateral distraction technique O‐A
C2‐3 distraction
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Saccades with Balance and Cervical Proprioception
Feasibility of Early PT for Dizziness After SRC: a RCT Reneker JC1, Hassen A2, Phillips RS2, MoughimanMC3, Donaldson M2, Moughiman J3
Scand J Med Sci Sports. 2017 Feb 17. doi: 10.1111/sms.12827. [Epub ahead of print
• Subjects aged 10‐23 years old with acute concussion and dizziness were enrolled from sports medicine centers.
• Forty‐one participants were randomized into treatment and were seen for physical therapy beginning at 10 days post‐concussion.
• Subjects in the experimental group received individually tailored, pragmatically delivered progressive interventions.
• Subjects in the control received prescriptive sham to minimally progressive interventions.
• The two primary outcomes were medical clearance for return‐to‐play and symptomatic recovery.
• The median number of days to medical clearance for the experimental group was 15.5 and for the control was 26.
• The median number of days to symptomatic recovery was 13.5 for the experimental group and was 17 for the control.
Role of Vestibular / Ocular Rehab Return to Play / Activity
• Does the patient have skewed/blurred vision while body in motion/head turning?
• Do they have continued headaches?
• Do visual tasks increase their symptoms?
• Critical missing link of full sensory integration of visual / vestibular / somatosensory system?
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http://www.eastneurology.com.au/images/BPPV%202.jpg
You Have To Train All Systems!
Convergence Exercises
• Pencil Push Ups (do not overtrain!)
• Brock String
• Arrow Chart/Dot Card
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Pencil Push‐Ups – WARNING!!!
• DO NOT DO IN ACUTE PHASE FOCAL BINDING
• If send home for practice make sure they have someone watching them
• ODs don’t send home pencil push ups because lacking neuro‐cognitive feedback
• Don’t train the test
How Do You Make Convergence Functional?
What about Convergence and Reaction Time?
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Convergence and Balance……
Accommodation Training
• Brock String
• Near/Far Heart Charts
Functional Accommodative Training….
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Adaptation Exercises
• VOR x 1 and x 2 viewing exercises• Progression:
• Duration, goal up to 2 minutes continuous
• Velocity
• Patterned/Busy backgrounds
• Position
• Target Distance
Vestibular Exercises
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Substitution
• Substitution of other strategies to replace the lost or impaired function
• Eye tracking
• Oculomotor Exercises
• Saccades
• Eye head coordination exercises
• Remembered Targets
Cheap Dynavision……
Substitution
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Oculomotor and Balance
Progression• Adaptation (if there is something to adapt)
• Substitution (this includes oculomotor component)
• Habituation
• Add balance component into all of above or separately
Exertional Testing and Prescription
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Return to Play Protocol
Return to Activity in Conjunction with VOD?
• VOD home program + PT/Vision Therapy weekly
• Return to school with accommodations
• Walking 20 mins/day initiated early (Exertional therapy)
• Return to Play/Activity Progression Stage III/IV Progression• NPC < 6cm
• VOR 160 bpm with no symptoms
• Tolerance of fast smooth pursuits with no symptoms
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What About Visual Motion Sensitivity ?
Factors that May Trigger or Exacerbate Headaches
• Cervical spine injury
• Impaired sleep
• Higher level cognition
• Vision
• Hearing sensitivity
• Exercise
Complementary Therapies….
• Orthopedic Management of Cervical Spine• Manual therapy
• Dry Needling
• Strengthening
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Dry Needling
Concussion Rehab Focus
• Fine Motor Deficits/Reaction Time
• Vision
• Eye head coordination
• Neck Pain/Proprioception Dysfunction
• Headaches
• Fatigue/Exertion
• Balance/Coordination
• Dual task performance
• Body Mechanics and Posture
• Safe return to activity
WHAT YOU DON’T SEE IS WHAT YOU GET!
© 2016 Dynavision International, LLC
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What We’ve Learned……• It is more than just balance
• Vestibular/Ocular Component is missing Link
• On Field Markers that Predict Complicated Recovery?
• Outcomes are highly variable
• Vestibular‐related symptoms (dizziness/fogginess) and migraine history/symptoms best predict protracted recoveries
• Effective sideline management is key‐removal from play a must when symptoms occur
• Return to play prior to full recovery from concussion will result in worse outcome and less force causing re‐injury.
• Neurocognitive testing is an effective tool to help quantify the injury and guide the management and RTP process.
• The “mild” injuries may become complicated and the “severe” injuries may become mild
• Proper Clinical management is best form of prevention
• Targeted clinical pathways for treatment and rehabilitation are being established
Questions?
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Equipment• Bernell: extensive vision training products
• www.bernell.com
• 1‐800‐348‐2225
• Optometric Extension Program Foundation (OEPF): specialty vision training products
• www.oepf.org/products
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