10/24/2018 Disclosures No disclosures to report Exertion: Just Do - PDF document

10/24/2018 Disclosures • No disclosures to report Exertion: Just Do It! Annie Doda, DPT TRIA Orthopedic Center October 26, 2018 Objectives What is exertion? 1. Define exertion as it relates to concussion. • Exertion Definition https://corticalchauvinism.com/2013/03/20/key- players-in-autism-iii-brain-weight/ 2. Discuss the value of exercise during acute and protracted – the act or an instance of exerting; especially : a laborious or perceptible effort recoveries during concussion treatment/management. Exert 3. Demonstrate understanding of formal exertion therapy, • a : to put forth (strength, effort, etc.) various tools utilized for exertion assessment, and value of sport specificity. • b : to put (oneself) into action or to tiring effort ( https://www.merriam-webster.com/dictionary/exertion, 2018) Which athletes should be exerted? • All Sports Concussion Athletes – Often overlooked • Graduated RTS Strategy (McCrory et al, 2017) 1

10/24/2018 Who can assist athletes with exertion/RTP? Multi-disciplinary recommendations: Rehab • Berlin consensus (McCrory et al, 2017) – “closely monitored active rehabilitation programme involving controlled sub-symptom-threshold, submaximal exercise have been Exertion shown to be safe and may be of benefit in facilitating recovery” Patient – More research needed in this domain • CDC statement (Lumba-Brown et al, 2018) – Optimal timing not established – “inactivity beyond initial 3 days post concussion may worsen their self-reported symptoms” Parent Coach AT PT Multi-disciplinary Rehab recommendations (continued) • University of Pittsburgh-- Targeted Evaluation and Active Management (TEAM) Approach (Collins et al., 2015) For most cases, would we totally shut down – Are we behind? Typical course of medicine – 71% of US adults did not recognize concussion as treatable (Poll, an orthopedic patient for weeks after Harris, 2015) surgery/injury? • Pathophsyiology vs. symptoms and impairments – Need to find level of activity that is just right for patient- not too little, not too much • Avoiding contact remains important Optimal Loading Timing for activity? • Current practice and a • Great question! building body of evidence – Research for timing and type of exertion still needed and are multi- now encourage “optimal center studies currently recruiting loading” as opposed to • What we do know… rest; even for concussions – After 24-48 hour acute phase- gradual and progressive light aerobic patients activity (McCory et al, 2017) • Can be applied to non- – Shorter time initiation of aerobic exercise= faster full return to sport and school/work sport activities as well- – Bed rest 5 days= situational depression (Thomas, Apps, Hoffmann, choir, band, theater, etc. NcCrea &Hammeke, 2015) 2

10/24/2018 • 2 objectives Evidence to support active treatment during – Safe to perform Buffalo Concussion Treadmill Test (BCTT) acute the Acute/Sub-acute phase of recovery phase? – Prognostic factors? • Results: – No difference in recovery period – NO ADVERSE EFFECTS – Heart rate strongly predicted recovery prognosis Clinical Take Away • Using symptom threshold light aerobic activity is safe and beneficial – even assessments • Proposed- start day 6 post concussion: • Improves patient’s self-report of symptoms on Post- – 8 sessions Concussion Symptom Scale – 10 minutes in duration and exercise intensity 50% HRM • More structure- FITT principles need to be applied and – Next session 20 mins, same 50% investigated (Lawrence, Richards, Comper & Hutchinson, 2018) – Following sessions at 30 mins, 5% increase in HRM up to 70% Take away points: – Everyone completed safely! – Not formal PT- physician progressed – Reduction in symptom severity scores Benefits of Exercise: General • Favorable effects on brain neuroplasticity • Improved neuronal functioning Active treatment with prolonged recovery • Aerobic exercise cognitively protective – Associated with greater levels BDNF • Promotes conditioning of CV system • Mood/overall well being (Leddy et al, 2016) ) https://newlyfitlife.wordpress.com/2015/02/13/lol-of-the-week/ 3

10/24/2018 Aerobic Activity and Protracted Recovery (>3-4 weeks) – For consideration… • Important to identify concurrent ocular, vestibular, and cervical symptom contributions Formal Exertion Therapy • Previous recommendations: rest until asymptomatic – Rat vs. Human Models- Humans can identify symptom= SUB- SYMPTOM THRESHOLD – Use BCTT to identify physiologic response (Leddy, Baker, Haider, Hinds & Wiler, 2017) • Not always long intervention- 4 week program improved symptoms in adolescents with mean 7 weeks of persistent symptoms (Gagnon, Galli, Friedman, Grilli & Iverson, 2009) Formal Exertion Therapy: Who? Autonomic Dysregulation Theory • normal progression of Return to Sport Strategy • Initial decreased Cerebral Blood Flow – previous history of concussion or other co-morbidities- want formal • Altered ANS connections to cardiac system evaluation • Increased cerebral blood flow during exercise= symptoms • progression from basic vestibular interventions to higher level • Assessed: Buffalo Concussion Treadmill Test vestibular with exertion emphasis • Deconditioning (Leddy, Hinds, Sirica, Willer, 2016) • Increased fear/anxiety • Address physiologic intolerance to exercise due to concussion sequelae- autonomic dysregulation Formal Exertion Therapy: Exertion tools utilized Formal Exertion Therapy: When to initiate? • Major vestibular, ocular or cervical identified • Buffalo Concussion Treadmill Test • Exertion/Sport specificity can be concurrent • TRIA Active Assessment • Clinical Pearl: Low symptom profile, Timeline varies • TRIA Clearance Test • Sport specificity • Graduated RTP strategy 4

10/24/2018 Formal Exertion Therapy: Buffalo Concussion Formal Exertion Therapy: Sport Specific Treadmill Test Circuits/Activities Demands of each sport/activities can vary, but also have Validated and • commonalities (swimmer vs gymnast vs football vs lacrosse) reliable (Leddy, Willer, 2013) • Common: reaction time, turns, aerobic demands • Sport Specific: Safe with • pediatric – Swimmer: horizontal, vestibular rich environment population – Gymnast: space/body awareness, inverted movements (Cordingly et al, 2016) – Football: contact, designed plays, position dependent – Lacrosse: contact, position dependent, use of stick Exercise induced • vs. concussive related (Leddy & *Typically most motivating to pts Willer, 2013) Formal Exertion Therapy: PT sessions Formal Exertion Therapy • All PTs capable of performing all aspects of concussion • Breakdown to the various treatment aims management – Typically a combination – Vestibular – Targeted limitations to be addressed: – Cervical • High Level Vestibular sensitivity with exertion emphasis • Autonomic Dysregulation – Exertion • Deconditioning • Clinic Athletic Trainers lead progression/sport specificity • Anxiety/Fear Treatment: High Level Vestibular sensitivity Treatment: Autonomic Dysregulation with exertion emphasis • (+) BCTT Identify sub-maximal threshold 20 minutes subthreshold intensity (80% of HR achieved on BCTT) 5-6 days/week Increased 5-10 bpm every 2 weeks Physiologic resolution – voluntary exhaustion 85-90% HR for 20 mins w/o symptoms (Leddy & Willer, 2013) 5