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

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

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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

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Exertion: Just Do It!

Annie Doda, DPT TRIA Orthopedic Center October 26, 2018

Disclosures

  • No disclosures to report

Objectives

  • 1. Define exertion as it relates to concussion.
  • 2. Discuss the value of exercise during acute and protracted

recoveries during concussion treatment/management.

  • 3. Demonstrate understanding of formal exertion therapy,

various tools utilized for exertion assessment, and value of sport specificity.

What is exertion?

  • Exertion Definition

– the act or an instance of exerting; especially : a laborious or perceptible effort

Exert

  • a : to put forth (strength, effort, etc.)
  • b : to put (oneself) into action or to tiring effort

(https://www.merriam-webster.com/dictionary/exertion, 2018)

https://corticalchauvinism.com/2013/03/20/key- players-in-autism-iii-brain-weight/

Which athletes should be exerted?

  • All Sports Concussion Athletes

– Often overlooked

  • Graduated RTS Strategy

(McCrory et al, 2017)

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Who can assist athletes with exertion/RTP?

Exertion Patient Parent Coach AT PT

Multi-disciplinary recommendations: Rehab

  • Berlin consensus (McCrory et al, 2017)

– “closely monitored active rehabilitation programme involving controlled sub-symptom-threshold, submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery” – 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”

Multi-disciplinary Rehab recommendations (continued)

  • University of Pittsburgh-- Targeted Evaluation and Active

Management (TEAM) Approach (Collins et al., 2015)

– Are we behind? Typical course of medicine – 71% of US adults did not recognize concussion as treatable (Poll, Harris, 2015)

  • 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

For most cases, would we totally shut down an orthopedic patient for weeks after surgery/injury? Optimal Loading

  • Current practice and a

building body of evidence now encourage “optimal loading” as opposed to rest; even for concussions patients

  • Can be applied to non-

sport activities as well- choir, band, theater, etc.

Timing for activity?

  • Great question!

– Research for timing and type of exertion still needed and are multi- center studies currently recruiting

  • What we do know…

– After 24-48 hour acute phase- gradual and progressive light aerobic activity (McCory et al, 2017) – Shorter time initiation of aerobic exercise= faster full return to sport and school/work – Bed rest 5 days= situational depression (Thomas, Apps, Hoffmann, NcCrea &Hammeke, 2015)

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Evidence to support active treatment during the Acute/Sub-acute phase of recovery

  • 2 objectives

– Safe to perform Buffalo Concussion Treadmill Test (BCTT) acute phase? – Prognostic factors?

  • Results:

– No difference in recovery period – NO ADVERSE EFFECTS – Heart rate strongly predicted recovery prognosis

  • Proposed- start day 6 post concussion:

– 8 sessions – 10 minutes in duration and exercise intensity 50% HRM – Next session 20 mins, same 50% – 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

Clinical Take Away

  • Using symptom threshold light aerobic activity is safe and

beneficial – even assessments

  • Improves patient’s self-report of symptoms on Post-

Concussion Symptom Scale

  • More structure- FITT principles need to be applied and

investigated (Lawrence, Richards, Comper & Hutchinson, 2018)

Benefits of Exercise: General

  • Favorable effects on brain neuroplasticity
  • Improved neuronal functioning
  • 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/

Active treatment with prolonged recovery

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Aerobic Activity and Protracted Recovery (>3-4 weeks) – For consideration…

  • Important to identify concurrent ocular, vestibular, and cervical

symptom contributions

  • 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 Formal Exertion Therapy: Who?

  • normal progression of Return to Sport Strategy

– previous history of concussion or other co-morbidities- want formal evaluation

  • progression from basic vestibular interventions to higher level

vestibular with exertion emphasis

  • Deconditioning
  • Increased fear/anxiety
  • Address physiologic intolerance to exercise due to concussion

sequelae- autonomic dysregulation

Autonomic Dysregulation Theory

  • Initial decreased Cerebral Blood Flow
  • Altered ANS connections to cardiac system
  • Increased cerebral blood flow during exercise= symptoms
  • Assessed: Buffalo Concussion Treadmill Test

(Leddy, Hinds, Sirica, Willer, 2016)

Formal Exertion Therapy: When to initiate?

  • Major vestibular, ocular or cervical identified
  • Exertion/Sport specificity can be concurrent
  • Clinical Pearl: Low symptom profile, Timeline varies

Formal Exertion Therapy: Exertion tools utilized

  • Buffalo Concussion Treadmill Test
  • TRIA Active Assessment
  • TRIA Clearance Test
  • Sport specificity
  • Graduated RTP strategy
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Formal Exertion Therapy: Buffalo Concussion Treadmill Test

  • Validated and

reliable (Leddy, Willer, 2013)

  • Safe with

pediatric population (Cordingly et al, 2016)

  • Exercise induced
  • vs. concussive

related (Leddy & Willer, 2013)

Formal Exertion Therapy: Sport Specific Circuits/Activities

Demands of each sport/activities can vary, but also have commonalities (swimmer vs gymnast vs football vs lacrosse)

  • Common: reaction time, turns, aerobic demands
  • Sport Specific:

– Swimmer: horizontal, vestibular rich environment – Gymnast: space/body awareness, inverted movements – Football: contact, designed plays, position dependent – Lacrosse: contact, position dependent, use of stick *Typically most motivating to pts

Formal Exertion Therapy: PT sessions

  • All PTs capable of performing all aspects of concussion

management

– Vestibular – Cervical – Exertion

  • Clinic Athletic Trainers lead progression/sport specificity

Formal Exertion Therapy

  • Breakdown to the various treatment aims

– Typically a combination – Targeted limitations to be addressed:

  • High Level Vestibular sensitivity with exertion emphasis
  • Autonomic Dysregulation
  • Deconditioning
  • Anxiety/Fear

Treatment: High Level Vestibular sensitivity with exertion emphasis Treatment: Autonomic Dysregulation

  • (+) 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)

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Treatment: Deconditioning

General Strength and conditioning Exercises

Treatment: Anxiety/Fear

  • 0-100% where are you at?

– What is that remaining 10%

  • Often times contact/game intensity

Summary

  • All concussed athletes need to pass RTS

– Includes exertion components!

  • PT can help with RTS, further assessment of prolonged symptoms

– High level vestibular sensitivity – Autonomic Dysregulation – Deconditioning – Anxiety/Fear

  • Formal assessments tease sensitivities

– BCTT – TRIA Active Assessment

  • Sport specificity is key
  • More research needed

Thank you! References

  • Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to full functioning after graded exercises assessment and progressive exercise treatment of

postconcussion syndrome. Rehab Res Pract. 2012;705309.

  • Collins M, Kontos A, Okonkwo D, Almquist J, Bailes J, Barisa M, et al. Concussion is Treatable: Statements of Agreement form the Targeted Evaluation and Active

Management (TEAM) Approaches to Treating Concussion Meeting held in Pittsburgh, October 15-16, 2015. NeuroSurgery 2016 December; 79(6): 912-929. doi:10.1227/NEU.0000000000001447.

  • Cordingley D, Girardin R, Reimer K, et al. Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. J Neurosurg

Pediatr 2016;18:693-702.

  • Gagnon I, Galli C, Freidman D, Grilli L, Iverson GL. Active rehabilitation for children who are slow to recover following sport-related concussion, Brain Injury

2009;23(12):956-964

  • Lawrence DW, Richards D, Comper P, Hutchinson MG (2018) Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion. PLoS

ONE 13(4): e0196062. https://doi.org/10.1371/journal.pone.0196062.

  • Leddy JJ, Baker J, Haider MN, Hinds A, Willer B. A Phsyiologic Approach to Prolonged Recovery from Sport-Related Concussion. Journal of Athletic Training

2017;52(3):299-308.

  • Leddy JJ, Hinds A, Miecznikowski J, Darling S, Matuszak J, Baker J, et al. Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: a

Randomized Trial. Clin J Sport Med 2017;0:1-8.

  • Leddy JJ, Hinds A, Sirica D, Willer B. The Role of Controlled Exercise in Concussion Management. PM R 2016;S91-S100
  • Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin. J. Sport Med.

2010;20:21-7.

  • Leddy JJ, Willer B. Use of Graded Exercise Testing in Concussion and Return-to-Activity Management. American College of Sports Medicine 2013; 12(6);370-376.
  • Lumba-Brown A, Yeates K, Sarmiento K, Breiding M, Haegerich T, Gioia G, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and

Management of Mild Traumatic Brain injury Among Children. JAMA Pediatr 2018; doi:10.1001/jamapediatrics.2018.2853

  • McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October
  • 2016. Br J Sports Med 2017; 51: 838-847.
  • Merriam-Webster (2018) Accessed 10/14/18. https://www.merriam-webster.com/dictionary/exertion
  • Micay R, Richards D, Hutchinson MG. Feasibility of a post-acute structured aerobic exercise intervention following sport concussion in symptomatic adolescents: a

randomized controlled study. BMJ Open Sport & Exercise Medicine 2018;4:e000404. doi:10.1136/bmjsem-2018-000404

  • Poll, Harris. How knowledgeable are American about concussions?. Assessing and recalibrating the public’s knowledge. 2015. http://rethinkconcussions.com/wp-

content/uploads/2015/09/harris-poll-report.pdf

  • Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sports-related concussion: a systematic review. Br J Sports Med 2017;51:930-

934.

  • Thomas DG, Apps JN, Hoffman RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trail. Pediatrics. 2015;135(2):213-241.