3. OBJECTIVES
‣ REVIEW CATEGORIES OF NEUROLOGICAL FUNCTION
MOST COMMONLY AFFECTED BY CONCUSSION
‣ NAVIGATE A SYSTEMS-BASED APPROACH TO
RETURN TO PLAY AFTER CONCUSSION
‣ BRIEFLY REVIEW STRATEGIES/PITFALLS OF
CONCUSSION REHABILITATION
4. CASE
15 y/o M soccer player collides with another player, head-
to-shoulder, during a scrimmage and falls to the ground. He
is slow to get up and is noted to be “wobbly” coming off the
field. The ATC at the game notes that he is slow to respond
to questions so he is restricted from returning to the game.
He is held out of practice for one week and prior to the next
scrimmage, he reports that he is “all better.”
7. DIAGNOSIS
SHAKING INJURY TO THE BRAIN
- IMAGING NORMAL
- FUNCTION ABNORMAL
- SYMPTOMS ONSET WITHIN 24HR OF INJURY
Leddy J, Baker JG, Haider MN, Hinds A, Willer B. A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. J Athl Train. 2017;52(3):299-308. doi:10.4085/1062-6050-51.11.08
“SLOWED DOWN”
HEADACHES
DIZZINESS
NAUSEA
FATIGUE
LIGHTHEADEDNESS
10. EXPERIMENTAL HUMAN STUDIES SHOW THAT CONCUSSION
AFFECTS ANS CONTROL OF VENTILATION, PACO2 LEVELS, AND CBF.
ELEVATED PACO2 LEVELS AND CBF DURING EXERCISE ARE
ASSOCIATED WITH SYMPTOMS THAT REDUCE EXERCISE
TOLERANCE IN CONCUSSED PATIENTS.
Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249/JSR.0000000000000505
11. ANS DYSFUNCTION
CEREBRAL BLOOD FLOW ABNORMALITIES
BREATHING, HR REGULATION, CO2 MANAGEMENT
Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249/JSR.0000000000000505
15. THE FIRST RCT TO SHOW THAT INDIVIDUALIZED SUBSYMPTOM
THRESHOLD AEROBIC EXERCISE TREATMENT PRESCRIBED TO
ADOLESCENTS WITH CONCUSSION SYMPTOMS DURING THE FIRST
WEEK AFTER SRC SPEEDS RECOVERY AND MAY REDUCE THE
INCIDENCE OF DELAYED RECOVERY.
Leddy JJ, Haider MN, Ellis MJ, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019;173(4):319–325. doi:10.1001/jamapediatrics.2018.4397
16.
17. MANAGEMENT
ACUTE PHASE: FIRST 24-48 HOURS (V 4TH
CONSENSUS STATEMENT)
EARLY EXERCISE >>> ABSOLUTE REST
- SUB SYMPTOM THRESHOLD EXERTION IN A GRADED
FORMAT (ARP)
19. RTP PROTOCOL
1) LIGHT EXERCISE- WALKING OR BIKING
2) MODERATE SPORT SPECIFIC ACTIVITY
3) VIGOROUS NON-CONTACT EXERCISE/RESISTANCE
TRAINING
4) PRACTICE W/ BODY CONTACT
5) RETURN TO PLAY
PROGRESSION BASED ON SYMPTOMS
20. ARP RISKS
MINIMAL TO NONE, ESPECIALLY WHEN MONITORED
MAIN RISK: EXACERBATING SYMPTOMS
“PUSHING THROUGH” CAN PROLONG RECOVERY
23. 100 ADOLESCENTS
MEAN AGE OF 14.5 YEARS
69% HAD ONE OR MORE OF THE FOLLOWING VISION DIAGNOSES:
ACCOMMODATIVE DISORDERS (51%), CONVERGENCE
INSUFFICIENCY (49%), AND SACCADIC DYSFUNCTION (29%).
IN ALL, 46% OF PATIENTS HAD MORE THAN ONE VISION DIAGNOSIS.
Master CL, Scheiman M, Gallaway M, et al. Vision Diagnoses Are Common After Concussion in Adolescents. Clin Pediatr (Phila). 2016;55(3):260-267. doi:10.1177/0009922815594367
24.
25. INVERSE RELATIONSHIP BETWEEN VOMS
AND EXERCISE TOLERANCE
MORE SYMPTOMATIC WITH VOMS= LOWER TOLERANCE
NPC > 15CM = LOWER TOLERANCE
29. Brown, N., Mannix, R., O'Brien, M., Gostine, D., Collins, M. and Meehan, W., 2014. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. PEDIATRICS, 133(2), pp.e299-e304.
30. TAKE-HOME MESSAGE
THERE ARE SAFE LEVELS OF
COGNITIVE ACTIVITY THAT THE
CONCUSSED PATIENT CAN TOLERATE
WITHOUT RISK OF PROLONGING
SYMPTOMS
35. STUDENTS SUFFERING A CONCUSSION ARE
AT INCREASED RISK FOR POOR MENTAL
OUTCOMES
MULTIFACTORIAL (SCHOOL, ACTIVITY LEVEL,
ETC.)
INJURY ITSELF
Yang MN, Clements-Nolle K, Parrish B, Yang W. Adolescent Concussion and Mental Health Outcomes: A Population-based Study. Am J Health Behav. 2019;43(2):258-265. doi:10.5993/AJHB.43.2.3
36. PRO-INFLAMMATORY CYTOKINE LEVELS MAY
PERSISTENTLY REMAIN ELEVATED IN THE TIME
FRAME THAT POST-TBI DEPRESSION SYMPTOMS
MAY PERSIST
Yang MN, Clements-Nolle K, Parrish B, Yang W. Adolescent Concussion and Mental Health Outcomes: A Population-based Study. Am J Health Behav. 2019;43(2):258-265. doi:10.5993/AJHB.43.2.3
37. RISK FACTORS
FOOTBALL HAS THE HIGHEST RATE AMONG HIGH
SCHOOL ATHLETICS
PROLONGED RECOVERY- YOUNGER ATHLETES, PRIOR
CONCUSSION (ESP. IF PROLONGED RECOVERY),
FEMALE SEX, CONCOMITANT MOOD DISORDER
38. CLEARANCE?STEP 5 ARP/RTP PROTOCOL
BACK TO THE CLASSROOM
NORMAL VISUAL/VESTIBULAR EXAM
SYMPTOM FREE (INCLUDING MOOD, OR BEING ADDRESSED)
39. COMPLEX RTP DECISIONS
LONG-TERM IMPLICATIONS?
HOW MANY IS TOO MANY?
3-4?
PROLONGED SYMPTOMS?
NEW BASELINE/PERSISTENT DEFICITS?
LOWER IMPACT AND LONGER RECOVERY
LITERATURE IS NOT
CLEAR,
MULTI-DISCIPLINARY
DECISION
