Presentation Transcript

1. Safe Return to Activity (RTA) After Mild Traumatic Brain Injury (mTBI)

2. OBJECTIVES Review what is a mild Traumatic Brain Injury including causes and symptoms associated with concussion. Discussion on assessment of concussions and implications Management of concussions including school accommodations Role of Physical Therapy to allow your student/athlete to safely return to play.
3. New Minnesota Law CHAPTER 90--S.F.No. 612. Effective September 1, 2011 Minnesota State Law requires coaches and/or officials To remove youth athletes from participating in any youth athletic activity when the youth athlete exhibits signs, symptoms, or behaviors consistent with a concussion; or is suspected of sustaining a concussion. In order to return to activity the youth must be symptom free & evaluated by a provider trained and experienced in evaluating & managing concussions Coaches and officials must complete an online training every 3 years https://www.revisor.mn.gov/laws/?id=90&year=2011&type=0
4. History of the Neurotrauma clinic at Gillette
5. Gillette Children’s Neurotrauma Clinic Began May 2007 Children between 0-21 years Mild to moderate injury Patient Seen -over 1700 Mechanisms of Injury Sports MVA Car vs bike Car vs pedestrian Falls Assault Brain Injuries Fractures and Bleeds Spine Injuries Cervical strains Fractures Compression fracture SCIWORA
6. REVIEW OF MILD TBI’S
7. Traumatic Brain Injury “Defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head.” http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf
8. Concussion - Definition Complex process affecting the brain Induced by traumatic forces Direct or Indirect Functional Disturbance rather than Structural Injury No abnormality on standard structural neuroimaging Have seen students/athletes after concussion who have had an MRI and because it is normal they are told to return to activity.
9. Acceleration/Deceleration Brain moves forward in skull Frontal lobes strike inside of skull Rebound contre coup injury to the occipital lobe
10. Rotational Injury Brain rotates on axis causing stretching/tearing of axon Stretching and tearing of blood vessels results in hematoma Brain strikes skull causing contusion
11. Causes of TBI Sports-Related Head Injuries: 300,000 per year in U. S. Recreation TBI Deaths: > 500 per year MVA Other Assaults Sports Centers for Disease Control and Prevention 2000
12. Mild Traumatic Brain Injury Results in a graded set of clinical syndromes that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course Typically associated with grossly normal neuroimaging studies Acute clinical symptoms reflect a functional disturbance rather than structural injury
13. Mild Traumatic Brain Injury Mild TBI can cause functional changes, which are interactive: Cognition (learning, memory and reasoning) Sensation Language (communication, expression, and understanding) Emotion (depression, anxiety, personality changes, aggression, acting out, social inappropriateness)
14. 500 K+ 10 2 6 12 20 30 6 24 3 6 Glucose Calcium Glutamate hours days minutes 400 Cerebral Blood Flow 300 % of normal 200 100 50 0 (Giza & Hovda, 2001) UCLA Brain Injury Research Center
15. Guidelines for Return to Play Guidelines for return to play have been created with this data in mind, avoiding a time period where the brain is more vulnerable to injury due to the energy crisis of the brain Difficult to definitively define the period of vulnerability following TBI, each injury is different with varied effect on the cascade
16. ASSESSMENT OF MILD TBI
17. Assessment Physical exam to rule out bleed, neck injury, spine injury Neurocognitive screening/developmental screening CT scans and MRIs of the head are usually normal and are not necessary unless the patient has increasing symptoms of concern
18. Asking about symptoms Specific yes/no questions about the more subtle symptoms is more effective than asking open ended questions. “Asymptomatic” is not an easily defined term, though is at the core of proper concussion management
19. Symptoms may be delayed or recurrent Many athletes may seemingly “normalize” within minutes of an injury, but then have a recurrence and potential worsening minutes to hours later IMPLICATION: very rare same-day return to play
20. Signs and Symptoms Somatic: Headache, pressure, neck pain, n/v, vision changes, balance problems, light or noise sensitivity, “don’t feel right” Cognitive: Feeling “In a Fog”, difficulty concentrating or remembering, confusion Emotional: more emotional, sadness
21. Signs and Symptoms Physical Signs Loss of Consciousness, Amnesia, motor/sensory deficits Behavioral Changes Irritable, nervous Cognitive Impairment Slowed reaction times, memory or concentration deficits Sleep Disturbance Drowsiness, difficulty falling asleep
22. PCS Assessment/Referral PHQ-9 GAD-7 Pediatric Symptom Checklist Psychotherapy Psychology Psychiatry Pediatric, Adolescent, Adult Medicine Social Work Mood Disruption Emotional, Sadness, Nervousness, Irritability Somatic Symptoms Migraine, Headaches, Visual problems Dizziness/balance disturbance Noise/Light sensitivity Nausea Neck Pain/Spine Pain Cognitive Symptoms Attention problems, Memory dysfunction, “Fogginess”, Fatigue, Cognitive Slowing Headache Log Vestibular Therapy Physical Therapy Relaxation techniques Guided Imagery Integrative Medicine Clinic Neurology Ophthalmology ImPACT Testing Pediatric Symptom Checklist Vanderbilt ADHD Scale Driving Evaluation Speech Therapy Occupational Therapy Psychology Psychiatry Neuropsychology Sleep Alterations Difficulty falling asleep Sleeping less than usual Sleep Log Sleep Specialist
23. Neuropsychological Testing Objective evaluation of function Baseline testing may be helpful Allows comparison of baseline to post-injury tests If baseline testing is not available, compare to age-matched controls and a percentile generated
24. Facts for Physicians booklet   Acute Concussion Evaluation (ACE) form    ACE Care Plan Work version  School version   Concussion in Sports palm card   CDCHeads Up – Brain Injury in your Practice
25. MANAGEMENT OF MILD TBI’S
26. Goals of post injury management Prevent against Second Impact Syndrome Prevent against cumulative effects of injury Prevent presence of Post-Concussion Syndrome Determination of asymptomatic status essential for reducing repetitive and chronic morbidity of injury Post injury: cellular metabolism is over worked, thus the cells are more vulnerable to further insults and injuries.
27. Management Physical rest “Cognitive” rest Child needs to limit exertion with activities of daily living and limit scholastic activity while symptomatic Repeated injury or overstimulation during the energy crisis of acute brain injury could lead to cell death Pharmacology Management of specific symptoms Giza, Hovda. The Neurometabolic Cascade of Concussion. J Athl Train. Vol 36, p 228-235, 2001.
28. What is Cognitive Rest? Cognitive rest may also be called “brain rest” After a MTBI, we need to limit the activities that use “brain energy” so that the brain can function on the limited amount of energy it is creating. To help the brain heal and recover, some cognitive activities need to be limited temporarily.
29. What is Cognitive Rest? Some symptoms may worsen when engaging in cognitive and physical activities. This is the body’s way of indicating it is not able to make the amount the energy being demanded, activity should be stopped to allow body to rest.
30. What can be done on cognitive rest? OK to watch TV, watch movies, and listen to music. The volume should be low. Go to school and do homework; however if school and school work increases symptoms you may need accommodations at school, shortened school days or to stay home.
31. What is not allowed while on cognitive rest? No computer activities No video games No recreational reading No board games No card games No text messaging No computer activities No practicing musical instruments
32. What is physical rest? Physical rest is limiting the amount of energy spent in physical activity to allow the brain to use that energy to heal.
33. What can be done on physical rest? Walk with feet on the ground at a casual pace. Attend to school (no phy ed, gym class or recess).
34. What is not allowed while on physical rest? No sports No games No practices No gym/recess/exercise No strenuous activity No physical labor/work No amusement park rides No biking/skating/sledding/skiing No jumping
35. School Accommodations Approve dismissal for medical appointments related to this injury Reduced homework load. Limit to two hours maximum for all subjects per night. Limit computer time and reading requirements as needed Early dismissal/late arrival as needed Extended time for testing, homework etc
36. School Accommodations Eliminate non-essential work Rest period in Health Office during day as needed Wear hat or sunglasses for light sensitivity Preprinted class notes Utilize tools that address learning style: audio/video recorders, computers, etc
37. How can your student receive accommodations at school? First identify the contact person at your school: advisor, dean, principal. Alert the school and teachers of the injury as soon as possible. Arrange a meeting with the school to discuss school accommodations, bring in medical documentation.
38. Symptom Treatment REST!... the only known effective treatment for a concussion Encourage frequent breaks from studying Encourage good hydration and regular meals to avoid dehydration and hypoglycemic-related headaches
39. Student Athlete Management COGNITIVE REST If symptoms recur with cognitive activity, time off school may be needed Involve teacher, school nurse, principal, coach
40. PCS Management Antidepressants Anxiolytics Psychotherapy Mood Disruption Emotional, Sadness, Nervousness, Irritability Somatic Symptoms Migraine, Headaches, Visual problems Dizziness/balance disturbance Noise/Light sensitivity Nausea Neck Pain/Spine Pain Cognitive Symptoms Attention problems, Memory dysfunction, “Fogginess”, Fatigue, Cognitive Slowing Non-Pharm Headache Management OTC: NSAIDs Triptans Beta Blockers CCB Antiepileptics Antidepressants Flexeril Valium Amitriptyline Amantadine* (off label) Neurostimulants* (off label) Sleep Alterations Difficulty falling asleep Sleeping less than usual Behavioral: Sleep hygiene education, relaxation therapies, sleep schedule Pharmacologic: melatonin, amitriptyline, trazadone, short-term use of nonbenzodiazepines
41. Pediatric Athletes (<18) American Academy of Pediatrics (AAP) recommends “conservative” management: NO return to play on same day Seriously, NO return to play on same day When in Doubt, Sit them OUT!
42. High school athletes’ and their recovery from concussion Collins M, et al. Neurosurg 2006
43. Return to Play Normal imaging Normal physical exam Normal cognitive screen Symptom free - Medication free (without activity)
44. Role of Physical Therapy for Return to Activity Determine readiness to return Balance and vestibular assessments Stages for return to activity
45. Determining Readiness to Return to Activity
46. Readiness for Return to Activity No adolescent with a concussion should continue to play or return to a game after sustaining a concussion. Immediate Evaluation and Exam after a Concussion An individual sustaining a concussion should cease doing any activity that causes the symptoms of a concussion to increase (e.g. headaches, dizziness, nausea, etc.).
47. Readiness for Return to Activity If patients develop increased symptoms while doing a specific activity, that activity should be discontinued. Continuing activities, or exercise that increases symptoms, can delay the recovery from the concussion.
48. What are the risks of returning to activity before an injury is healed? Symptoms may last longer and become more intense. New symptoms may occur. Risk of repeat injury and risk of Second Impact Syndrome.
49. Explain Risks of Premature RTP before full recovery 2nd impact syndrome Death Higher risk in young athletes 2nd concussion, more severe Prolonged symptoms
50. Second Impact Syndrome In September of 2008, Jaquan Waller, 16, suffered a concussion during football practice at J.H. Rose High School in Greenville, N.C. A certified athletic trainer educated in concussion management wasn't onsite, and the school's first responder who examined Waller cleared him to play in a game two days later. During that game, Waller was tackled. Moments later, he collapsed on the sidelines. He died the next day.
51. Second Impact Syndrome A medical examiner determined Waller died from what is called second-impact syndrome, noting that "neither impact would have been sufficient to cause death in the absence of the other impact." Read more: http://www.time.com/time/magazine/article/0,9171,1873131,00.html#ixzz1SegF8gRE

52. Discussion/Quiz

53. When are patients referred for Return to Activity?
54. No athletes should return to contact competitive sports until they are symptom free, both at rest and with exercise and have normal neuro-cognitive testing. When they no longer have headaches or other concussion symptoms athletes can begin the concussion graduated return-to-play exercise program that was recommended at the Prague Concussion Conference.
55. Initial Evaluation Monitoring heart rate via use of a Polar Heart Rate Monitor. A strap with the monitor is placed around child’s upper body under chest and a watch is used to read their heart rate. Scapular/Cervical Screen Look at scapular (shoulder blade) alignment, upper extremity antigravity movement and cervical Range Of Motion: looking for symmetry & onset of cervical pain & substitutions
56. Strength screen for cervical musculature: It is very common (especially for girls and women) to overuse sternocleidomastoid (SCM) as compared to intrinsic musculature of the neck Some evidence that cervical weakness contributes (or is at least correlated with) repeat concussion in girls Look at chin tuck against gravity: any substitution with SCM? Check general isometric strength screen for cervical spine: looking for cervical pain
57. Balance Tests
58. BESS Balance Error Scoring System (BESS) Can be used by athletic trainers immediately following concussion on the sidelines Utilized in the clinic as well to assess higher level balance
59. BESS 6 testing positions All positions are preformed with eyes closed Each position is held for 20 seconds Count number of errors that occur
60. BESS Testing Positions
61. Errors noted during the BESS Hands lifted off iliac crest Opening eyes Step, stumble, fall Moving hip into more than 30 degrees of flexion or abduction Lifting forefoot or heel off floor Remaining out of testing position for more than 5 seconds **The maximum total errors for 1 testing position is 10 errors**
62. BESS Insert Bess videos
63. Video Functional Gait Analysis
64. Vestibular Evaluation
65. Vestibular Assessment Patients frequently complain of headache, dizziness, and vision problems following concussion Oculomotor and Vestibular systems are assessed on all patients at initial evaluation
66. What are the goggles? Infrared video goggles which help us to view eye movements Allows for observation and video recording of eye movements in both light and in the dark with the vision occluded Simultaneously records audio (important for later interpretation)
67. Real Eyes xDVR
68. Who is appropriate for the goggles? Patients from neurotrauma clinic Patients complaining of Headache Dizziness Nausea Difficulty with reading/schoolwork Referred for “balance and vestibular testing only”
69. What tests are done with the goggles on in the light? Saccades Vertical and Horizontal Smooth Pursuits Horizontal Vertical Diagonal Head Thrust Vergence Gaze Holding
70. What tests are done with the goggles and vision obstructed? Resting nystagmus Following pts own finger, while moved by therapist Hallpike Dix Headshaking nystagmus
71. Smooth Pursuits Hold finger or pen 18-24 inches away from face Ask child to follow slowly moving object 30 degrees side to side and up and down Normal: smooth, conjugate eye movements Abnormal: jerky or saccadic Video Clip Smooth conjugate eye movements Jerky or saccadic eye movements
72. Saccades Hold finger or sticker 15 degrees to one side of your nose Ask child to look at your finger then your nose, back and forth several times Repeat right/left and up/down Normal: <2 saccades Abnormal: >2 saccades Video of saccades
73. Head Thrust Sit in front of the child, holding their head in your hands Warn the child you will be turning their head quickly Have the child fixate on your nose as you slowly turn their head side to side Quickly and unexpectedly move the head to 1 side Repeat 2-3 times to each side of the head
74. Normal: Able to keep eyes on target Abnormal: Corrective saccade to move eyes back to target Insert Video Head Thrust
75. Vergence Hold a finger or small toy 2 feet away from the child Have the child maintain focus as you move it closer to the nose Normal: Symmetrical convergence to the object Abnormal: Dysconjugate, asymmetrical gaze, vergence response (point where object doubles) >5 cm
76. Vergence Insert Video
77. Gaze Holding Have child begin by gazing straight forward Have them gaze in all 9 directions (think tic-tac-toe board) holding each for 3-5 seconds Normal: No nystagmus, able to hold position Abnormal: nystagmus, rebound nystagmus, inability to hold the position
78. Gaze Holding Insert video
79. Benign Paroxysmal Positional Vertigo Assessment Hallpike Dix Done with vision obstructed Assess BPPV Have child long sit on mat with head turned 45 degrees to one side Hold the child’s head keeping the rotation, then quickly lie them down with head over the edge of the table in ~20 degrees of extension Ask patient to keep their eyes open and ask about their symptoms
80. Insert video Hallpike Dix
81. Post Head Shaking Diagnoses an acute unilateral peripheral lesion Vision is obstructed Grasp patient’s head and tip it forward 30 degrees Rotate the head 20 times at a speed of 2 Hz Stop and have the child look straight ahead, keeping their eyes open Normal:< 2 beats nystagmus Abnormal:>2 beats of nystagmus toward more neurally active (intact, healthy) side
82. Vestibular Assessment Based on results of oculomotor and vestibular screen, patients are assigned home exercise programs Frequently done in addition to their graded return to activity

83. Return to Activity

84. Initial Evaluation We provide education to families on how to find target heart rate during evaluation Karvonen Heart Rate 220 – Age = Maximum Heart Rate Maximum Heart Rate – Resting Heart Rate = Heart Rate Reserve Heart Rate Reserve x Training percentage + Resting Heart Rate = Target Heart Rate
85. Onset of Symptoms during testing? During testing at the appropriate level, if there is new onset of symptoms, the patient should be cued to return to complete rest for 24 hours. Reschedule the patient for PT one to two days later At this visit, the patient can resume activity at the previous level (i.e. doesn’t have to start over from level I) NP/MD should be notified that symptoms returned, and at what level of activity, as well as the plan for return to PT
86. Return to activity Stages for Return To Play No activity and rest until asymptomatic Stage 1: Light aerobic exercise Stage 2: Sport-specific training Stage 3: Non-contact drills Stage 4: Full practice drills except contact Student/Athlete will take final ImPact test and if cleared will then return to full contact without limitations
87. STAGE I (Target Heart Rate – 30-40% of maximum exertion) Athlete should be able to speak freely, not out of breath during activities. Limit head movement/quick position changes; limit concentration activities
88. Stage IENDURANCE EXERCISES (Should sustain for 15-20 minutes) Walking on Treadmill Nu-Step/ stationary biking Upper Body Ergometer (UBE) Pool (swimming laps/ swimming drills, front & back crawl) Stepping laterally or forward over cones
89. Stage IUpper Extremity/ Lower Extremity Range Of Motion & Strengthening Exercises Lower extremity range of motion: Hamstring, Quadriceps & Calf (if needed) Upper Extremity: low weight elbow (bicep) curls Standing calf raises Straight leg raises (Quadriceps) and sidelying hip abduction/ hip extension (Gluteus Medius and Maximus)
90. Stage IBalance Exercises Tandem stance position Single leg stance (eyes open & eyes closed)
91. Stage ICervical Exercises Cervical isometric exercises in all directions (do not do if painful) Cervical AROM exercises (slowly) Scapular retraction in sitting or prone arms in 90° of abduction Pectoralis stretching at wall or over bolster Cervical retraining with chin tuck in supine for stabilization
92. STAGE II (Target Heart Rate - 40-60% of maximum exertion) Athlete should be able to still complete a sentence while performing exercises. Mild sweating.Allow some positional changes & head movement; low level concentration activities
93. Stage IIEndurance Exercises (Sustain for 20-25 minutes) Brisk walking on Treadmill, possible interval jogging (walk 3 minutes, jog 2 minutes, then repeat) Elliptical Stationary biking
94. Stage IIUpper Extremity/ Lower Extremity Strengthening Exercises Wall sits/ Squats/ lunges Basic Swiss ball core activities (abdominal crunches) Side steps (small squat) with Theraband around legs
95. Stage IIUpper Extremity/ Lower Extremity Strengthening Exercises Leg press Step up/ down, lateral step ups “Bicycling in Air” abdominal exercise Can return to all static stretching positions
96. Stage IIBalance Exercises Single leg stance with lower extremity reach in star pattern Single leg stance on foam surface Stepping forwards, sideways over cones Tandem stance on foam surface Begin activities with head movement Walking with head turns
97. Stage IICervical (neck) Strengthening Cervical extension in prone off table Cervical lateral flexion in side-lying Rotational crunches Prone (on belly) over ball with scapular (shoulder blade) drills (“Y”; “swimming”; Bilateral ER starting in “goal post”)
98. STAGE III (Target heart rate 60-80% of maximum exertion) Athlete should be able to state a couple words during activity.Can start to incorporate exercises outside, can begin to add concentration component to exercises
99. Stage IIIEndurance Exercises (25-30 minutes) Jogging on Treadmill Ladder board drills (quick steps in ladder board) – forward, sideways, in/out Elliptical or Stationary Bike Skipping or “Apple Pickers”, Carioca steps
100. Stage IIIEndurance Exercises (25-30 minutes) Side shuffling exercises with verbal directional changes Short sprints & ZigZag running “Running on Trampoline” (30-60 second intervals for speed) Basic Jumping Drills (shuttle jumping, jumping off step for form, single leg hopping)
101. Stage IIIUpper Extremity/Lower ExtremityStrengthening Exercises Animal walking positions (crab walk, inchworm, bear walk or duck walk) Plank holds (in multiple directions) Walking hands out on Swiss ball Lunges in circular pattern Sport Cord/ Theraband resisted lunges
102. Stage IIIBalance Exercises Step over cones with directional changes Single leg balance with Upper Extremity star reaching Squats/ Lunges on Bosu disc Single leg stance on foam – toss ball at trampoline
103. Stage IIICervical Strengthening Plyoball with crunches and drops (multiple positions) Holding crunch position drop/pass plyoball or weighted ball to patient including with rotation Rotational crunches with plyoball “V” up Kneeling on floor with elbows on therapy ball and completing CW/CCW with trunk in neutral Human Rolling Pin Any prior level cervical exercises
104. STAGE IV (Target heart rate 80-90% of maximum exertion). Athlete should not be able to state more than a couple words at a time.Continue to avoid contact activity, but resume aggressive training in all environments. May return to non contact practice activities if symptom free
105. Stage IVEndurance Exercises (Should be duration of 30 minutes) Treadmill running with interval sprints Plyometric drills (should do every 3rd day for plyometric training principles & emphasize form & quiet landing) Box jumping on floor first with 2 feet & then progress to box jumping with single leg (clockwise, counterclockwise, diagonal) Single/ double leg jumping over line Jump up/ down step
106. Stage IVEndurance Exercises (Cont.) Plyometric drills (should do every 3rd day for plyometric training principles & emphasize form & quiet landing) Box Jump with Drop Single leg bounding Tuck jumps Side to side quick step over cones with holds Side to side jumping over cones Alternating lunge jumps
107. Stage IVEndurance Exercises (cont.) Defensive shuffle with tennis balls for quick direction change (Roll 1 tennis ball to R as athlete approaches ball roll 2nd ball to L, keep athlete moving quickly. Give athlete goal of not letting ball travel past certain line) Dot Drills Running Stairs Sport specific activities (EXAMPLES) Soccer player – dribbling ball with cones, kicking ball Basketball player – running patterns with lay-ups Football player – running patterns with throwing ball
108. Stage IVUpper Extremity/Lower ExtremityStrengthening Exercises Can return to all Upper Extremity/ Lower Extremity strengthening exercises May return to lifting with team for upper and lower body strengthening when/if cleared to do so (Including free weights and machines).
109. Stage IVBalance Exercises Continue to initiate sport specific balance exercises Single leg squats on Bosu disc (black or flat side up) Rebounder activities on Bosu disc
110. Discharge from PT PT will plan to discharge once the patient has passed both maximal exertion and balance testing
111. Final Stage Athlete has now passed the final ImPact test and has been given clearance by provider for return to all contact drills. Recommendation: Have your student/athlete participate in 3 full practices including contact drills prior to playing in a game situation.
112. Case Study #1 Vestibular
113. Case Study #2 Return to Activity
114. Conclusions It is our responsibility to know what a concussion looks like. Concussions for young athletes are increasing and underreported. DO NOT RETURN ANY PLAYER TO PLAY THE SAME DAY A SUSPECTED CONCUSSION OCCURS. Symptoms may not be reported by the athlete for > 15’ so be very cautious if you suspect a concussion.
115. Conclusions (cont.) Young athletes who have a concussion need to have complete REST until symptom free. The most common symptoms associated with concussions are headaches, dizziness, “fogginess”, concentration/memory problems Once symptom free then slowly return to activity and monitor for any change in symptoms
116. ACCESS TO NT CLINIC
117. Gillette Children’s Neurotrauma Clinic What does an appointment entail? Height/Weight Nurse Appointment Developmental Screening under age 6 years ImPACT testing over the age of 10 years Who sees the patient? Neurosurgery Nurse Practitioner Physical Medicine and Rehabilitation Nurse Practitioner
118. Members of the Neurotrauma Team at Gillette Children’s Specialty Healthcare Physical Medicine and Rehabilitation Neurosurgery Neurology Physical Therapy Occupational Therapy Speech Therapy Psychology Neuropsychology Social Work Psychiatry Sleep Medicine