concussion rehab

Concussion Rehab Cristina Wingerter

Concussion ● form of mild Traumatic Brain Injury (TBI)

● 1.6 to 3.8 million sports-related concussions per year in the US(Langlois, 2006 )

● cognitive and perceptual changes after a blow to the head (Kasper, 2015)

● often sudden deceleration of head while hitting a stationary object

● A-P displacement of brain inside skull

Imaging

CT and MRI usually clear (i.e. no structural changes)

● CT : only detects hemorrhage and edema

● MRI: can detect small contusions, hemorrhages

● no current technology able to individually diagnose or establish safe return to

activity

GradeGrade 1: sx last for less <15 min. No LOC

Grade 2: sx last >15 min. No LOC

Grade 3: LOC (even for a few seconds)

Symptoms-PCS Post-Concussion Syndrome (PCS) -persistent syndrome beyond accepted timeframe (most sources say 3 months) (Carroll, 2004)

DSM IV definition:1) cognitive deficits in attention/memory 2) and at least three of the following:

a) fatigue b) sleep disturbance c) headachesd) dizziness e) irritability f) apathy

g) personality change

Predictors*female sex

*hx of concussions

*younger age (older teenager, young adult)

*hx cognitive dysfunction

*affective disorders (i.e. anxiety and depression)

*length of posttraumatic amnesia

*(severity is not a contributing factor to development of PCS)

Differential Dx*depression

*somatization

*chronic fatigue

*chronic pain

*cervical injury

*vestibular dysfunction

*visual dysfunction

Treatment Acute

- rest **

PCS

- education (MD)

- cognitive behavioral therapy (neuropsychologist)

- aerobic exercise therapy and vestibular therapy (PT)

PT involvement Acute

*on-field evaluation (sports and military)

Sub-Acute:

*balance/vestibular/neurologic screen

Rehabilitation:

*balance/vestibular therapy

*management of coexisting cervicogenic issue related to headaches/dizziness

*return to exertion

Exam: History *description of mechanism of injury

*force of head trauma

*hx of concussions, mechanism, sx, duration, amnesia

*hx of migraine, depression, anxiety, ADD/ADHD

-TBI can exacerbate these

*medications: most commonly prescribed antidepressants

Exam: Measures Symptoms

-post-concussion symptom scale (Lovell 2006)

-post-concussion symptom inventory (Gioia 2008)

Problem: underreporting common (McCrea, 2004)

Cognition

-neurocognitive testing (good if have baseline, not recommended stand alone)

Clinical Findings Vestibular

-dizziness 32.5% at 5 years in PCS (Kontos, 2012)

-causes: BPPV, Labyrinthine concussion, post traumatic migraine, brain stem

concussion

-assessing: (1) head thrust test

(2) Clinical dynamic visual acuity test

(3) head shake nystagmus test

Clinical Findings Abnormal Postural Control

-common acutely and subacutely (Kontos 2012)

- related to abnormalities in sensory organization

-ability to utilize and process vestibular information needed for postural control

affected (Peterson, 2003)

Testing: balance testing, gait assessment (dynamic gait index)

- appears to resolve more quickly than other symptoms following concussion

(Catena 2011)

Exertion -student athletes who engaged in high levels of activity in the weeks following

concussion had increased symptoms, worsened neurocognitive data and significantly

longer recovery time (Majerske et al. 2008)

Neurometabolic Cascade:

increasing energy demand and decreased blood supply→ metabolic crisis

Exertional Rehabilitation

Exercise ProsProlonged Rest:

-deconditioning

-fatigue

-reactive depression

-exercise positive effects on mental health

-exercise promotes neuroplasticity and enhances neuroprotective properties

(Griesbach et al, 2008)

Exercise Cons- animal studies: within 1st week impair cognitive performance but after 14-21

improved cognitive performance (Griesbach GS 2004)

PT Management

- systematic monitoring throughout session of HA and fogginess (mindful of

migraine provocation)

- proceed at slower rate than with peripheral injuries

- initial stages: exertional exercise may be contraindicated

- vestibular rehab, ocular motor training, management of cervicogenic issues, treat

BBPV with Canalith repositioning, sensory integration exercises, and balance

training

Graduated Return to Play Guidelines Rehabilitation Stage Functional Exercise Objective

No activity, complete rest sx limited physical and cognitive rest Recovery

Light aerobic exercise Walking, swimming, cycling, low intensity (below 70% HR). No RT

Increase HR

Sport specific exercise skating drills in hockey, running drills in soccer. no head impact

Add movement

Non-contact training drills Progression to more complex training drills Exercise, coordination and cognitive load

Full contact practice Following medical clearance participate in normal training activities

Restore confidence and assess functional skills by coaching staff

Game play Normal game play

Return to Play Athletes can gradually return to play if:

1) completely asymptomatic presentation

(during rest and activity)

2) normal neurocognitive evaluation

3) off medications (that mask sx)

Guidelines from International Conferences

on Concussion in Sports: Vienna 2001

Citations 1. The epidemiology and impact of traumatic brain injury: a brief overview.Langlois JA, Rutland-Brown W, Wald MMJ Head Trauma Rehabil.

2006 Sep-Oct; 21(5):375-8

2. Ropper AH. Concussion and Other Traumatic Brain Injuries. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds.

Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015.http://accessmedicine.mhmedical.com.ezproxy.simmons.edu:2048/content.aspx?bookid=1130&Sectionid=79756215. Accessed October 12, 2015

3. Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.Carroll LJ, Cassidy JD, Peloso PM, Borg J, von Holst H, Holm L, Paniak C, Pépin M, WHO Collaborating Centre Task Force on Mild Traumatic Brain InjuryJ Rehabil Med. 2004 Feb; (43 Suppl):84-105.

4. Coel RA, Hoang QB, Vidal A. Sports Medicine. In: Hay WW, Jr., Levin MJ, Deterding RR, Abzug MJ. eds. CURRENT Diagnosis &

Treatment: Pediatrics, 22e. New York, NY: McGraw-Hill; 2013.http://accessmedicine.mhmedical.com.ezproxy.simmons.edu:

2048/content.aspx?bookid=1016&Sectionid=61602855. Accessed October 12, 2015.

5. Leddy, J. Sandu, H. Sodhi, V. Rehabilitation of Concussion and Post-Concussion syndrom. Sports Health. 2012. 4(2):147-154.