Sport Physiotherapy Canada- Clinical Considerations for Interdisciplinary Care: Concussion Symposium

This past weekend, I had the opportunity to attend the first annual Sport Physiotherapy Canada Concussion Symposium. This conference focuses on the current best practices surrounding concussion management and the speakers included the top researchers, clinicians and neurosurgeons in the world. However, it wasn’t these “experts” that made this conference a memorable one, it was the guest speaker: Alecko Eskandarian. Last week I read an article from The Players’ Tribune written by Alecko (a former Toronto FC player). His story captivated me and I have been obsessing and posting his story on all my social media platforms ever since. Alecko is a former professional soccer player that was forced to retire after multiple concussions at the age of 27. If you haven’t read his featured article- stop now and go read it (http://www.theplayerstribune.com/alecko-eskandarian-soccer-concussions/). He talked for 30 mins about his professional career, his first, second, third and finally his fourth concussion. He also talked about the mis-management of his diagnosis and the culture of “what being a male professional athlete” was back then (and still is to this day). When he was initially diagnosed, the common protocol was rest until symptoms subsided and then get back into training. There were no Zurich protocols, no clinical diagnosing, his participation in soccer relied solely on his scans. So what’s the problem with this? If you look at our previous blogs, you’ll note that we are a big fan of active recovery. So the following will be a summary of the symposium and my biggest take-home points from the conference.

 

First off- What is a Concussion?

A concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.

 

When athletes get a concussion, they can present to the clinic with several different symptoms that affect several different systems in the body. This may include the cervical spine, vestibular system, occulomotor system, neurocognition and emotional and psychological changes. In addition, prolonged symptoms are often classified as post-concussion syndrome.

For the purpose of this blog, we’ll skim over the occulomotor, neurocognition and psychological changes as they are outside our scope of practice and the main focus will be on sub-threshold testing and treatment planning.

 

Occulomotor

In over 50% of traumatic brain injuries there is an associated occculo-motor dysfunction. This involves accommodation, versional and visual deficits. I won’t touch too much on this topic as it is outside my scope of practice. But the current treatment from a neuro-optometric standpoint is using prisms, lenses, tints, binasal occlusion, dry eye therapy and vision rehabilitation programs.

Key point: In terms of physio, the current evidence supports the use of cervical proprioceptive drills, vestibular therapy, postural facilitations and visually guided movements. If you would like further information regarding a neuro-optometric in your area go to: www.concussionvisionclinic.com

 

Clinical Neuropsychology

In most cases, cognitive recovery takes place within 1-7 days for athletes. However the following are a list of modifiers that impact cognitive recovery:

1. >10 days of higher number of symptoms
2. Amnesia
3. >1 min LOC
4. Concussive convulsions
5. Timing: recent concussion, close together, repeated concussions
6. Force: less impact with repeated concussions

Key point: The therapeutic alliance has the GREATEST impact on recovery. Knowing your athlete and creating a rapport is very important from a neurocognitive standpoint!

 

Psychological and Emotional

Concussions are generally seen as invisible injuries. Therefore as clinicians we often miss the emotional and psychological aspects of this diagnosis (especially if we haven’t worked with the athlete pre-concussion). Post-concussion, studies have shown an elevation in negative mood states: “depression”, poor sleep quality, low vigor, increased confusion, anger, fatigue and stress.

Key point: Take a detailed intake interview that includes risk and history of concussions, ask about emotions and follow up and monitor your athlete at each recovery milestone. KNOW your athlete or ask the athlete and his/her family regarding changes in personality.

 

Exercise and Rehabilitation in Children

Concussions in children are treated a little differently than the adult population. There is a higher recurrence rate in children, recovery length is longer and the danger of 2^nd impact syndrome, although rare, is high in this population.

Week Post	Percentage with persistent symptoms
1	56%
2	41%
4	30%
8	24%
12	20%

There is also a higher percentage of persistent symptoms several weeks post (see table). Note that even at one month out, 30% of the tested population still had persistent symptoms (classified as more than 3 symptoms). As a clinician, it’s also important to note that normative values are no longer “normative” values in a paediatric population and baseline testing much be tested more frequently.

Key points: In terms of treatment, it’s about RESTRICTION and not REMOVAL. Activation is good in children-let them be symptom limited. They should not be out of school for more than 2 days and a routine should be set in place early on to avoid poor sleep hygiene. Symptoms should resolve within 2 weeks and a gradual return to school and return to play protocol can be initiated. However, in children that have symptoms into weeks 3 and 4, educate the family and child that it is OK to push beyond symptoms. The speaker notes that the symptoms are more from de-conditioning than actual concussion symptoms. Remember in children you have to initiate both a return to SPORT and a return to LEARN program. The following is a link for both: CATT for educators

 

Equipment

There were a lot of questions regarding equipment such as headgear in soccer, mouth-guards in hockey, football helmets and other “gadgets and gizmos” that are “facilitating” concussion rehab. To date, there is very limited (if any) evidence to support the use of any of these “concussion reducing” devices.

Key point: If it gives you psychological comfort, use that headband or mouth guard.

 

Post Concussion Syndrome

Post concussion syndrome includes multiple symptoms, but is often defined as having symptoms longer than 6 weeks. If symptoms resolve within the first year, there is a good chance for recovery. However, if symptoms last for 2-3 years the chance for complete recovery reduces, and if persisting longer than 3 years, there is no complete recovery expected.

 

Sub-symptom Threshold Exercise (Buffalo Concussion Treadmill Test)

We have addressed this approach multiple times in previous blogs, but it was interesting to hear the evidence first hand from Dr. John Leddy. I won’t touch on the Buffalo Concussion Treadmill Test itself, as that was addressed by Dave in the last blog. However I wanted to discuss the research and evidence used to support this “new” approach to concussion management: active recovery.

Dr. Leddy attributes the facilitated return to play via sub-threshold exercise to the Autonomic Nervous System (ANS). The ANS is split into two systems: Sympathetic (fight or flight) and the Parasympathetic (rest and digest). These two systems control things like heart rate, blood pressure, skin temperature, digestion, etc…

 

In Dr. Leddy’s studies he shows that concussed athletes have:

1. A lower HR at rest and during exercise
2. A high rate of perceived exertion
3. A lower pulse pressure (SBP-DBP) which leads to a lower stroke volume and cardiac output
4. A lower cerebral blood flow
5. A lower carbon dioxide sensitivity

Therefore he concludes that there is an inability for the ANS to switch appropriately leading to cardiovascular dysfunction during exercise in adolescents with concussions.

He challenges the idea that the traditional “rest and black room” is actually detrimental secondary to the interference of cerebral blood flow regulation. Rather exercise increases cerebral blood flow, decreases fatigue and has the potential to change cognition, concentration and symptoms such as headaches.

New View

1. Educate
2. Rest for a few days
3. Use symptom limited thresholds and stay below it
   • If symptoms are longer than 6 weeks –perform the BCTT
4. Initiate return to play Zurich guidelines

 

Concussions are multi-faceted injuries with multiple symptoms. The current evidence supports the use of a multi-modal approach that includes clearing the cervical spine, vestibular system, occulo-motor deficits, mental and emotional changes and a neurocognitive test. Therefore an interdisciplinary approach is preferred. When it comes to physical therapy itself: evidence supports the use of manual physical therapy, vestibular rehab, postural retraining, proprioceptive retraining, sub-threshold training and an active gradual return to play protocol. Unlike Alecko’s story, return to sport should not rely solely on diagnostic imaging, rather concussions are a clinical diagnosis and therefore recovery is based on how the athlete presents in the clinic not under a diagnostic imaging machine.

 

TAKE HOME MESSAGES:

• EDUCATE: coaches, family, athletes
• Building a rapport with the athlete is the most important step in the process
• Change the culture around self-reporting symptoms
• Take a detailed history including emotional changes
• Children take longer to heal and should be symptom guided
• Equipment such as headgear, mouth guards and specific helmets have no evidence to support a decreased concussion rate
• Active recovery is better than passive rest
• Exercise is medicine- dose it appropriately

 

Keep posted for the most recent consensus statement on Concussion in Sport that took place in Berlin last month. Recommendations will be out in February 2017.

 

Apps:

Concussion Ed App

Parachute Canada

Canada’s Injury Compass