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Active Treatment and Rehabilitation Approaches for Concussion
Experts from UPMC Sports Medicine discuss active treatment and rehabilitation approaches for concussion as part of UPMC's 2013 conference "Emerging Frontiers in Concussion."
Upon completion of this activity, participants should be able to:
• Discuss the medical management of post-concussion syndrome in the areas of sleep dysregulation, mood disorders, and cognitive difficulties, as well as different types and causes of post traumatic headaches.
• Define the five stages of exertion therapy.
• Identify common vestibular abnormalities following concussion
• Review rehabilitation strategies to treat vestibular deficits
- Gail B., Parkhouse WS, Goodman D. Exercise following a sport induced concussion. British Journal of Sports Medicine. 2004; 38: 773-777.
- Geurts AC, Ribbers GM, Knoop JA, van Limbeek J. Identification of static and dynamic postural instability following traumatic brian injury. Arch Phys Med Rehabili. July 1996; 77(7):639-644.
- Guskiewicz KM. Postural stability assessment following concussion: one piece of the puzzle. Clin J Sport Med. Jul 2001;11(3): 182-189.
- Heikkila H, Johansson M, Wenngren Bl. Effects of acupuncture, cervical manipulation, and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Man Ther. Aug 2000; 5(3):151-157.
- Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res. Mar 2007;25(3):404-412.
- Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther. May 2009;39(5):364-377.
- Camiolo-Reddy, Collins, Lovell, Kontos, JHTR, 2012
- Hillier SL, Hollohan V. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2007(4):CD005397.
- Brown KE, Whitney SL, Marchetti GF, Wrisley DM, Furman JM. Physical therapy for central vestibular dysfunction. Arch Phys Med Rehabil. Jan 2006;87(1):76-81.
- Whitney SL, Wrisley DM, Brown KE, Furman JM. Physical therapy for migraine-related vestibulopathy and vestibular dysfunction with history of migraine. Laryngoscope. Sep 2000;110(9):1528-1534
- Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion. Journal of Neurologic Physical Therapy. 2010;34:87-93.
- Naguib MB, Madian Y, Refaat M, Mohsen O, El Tabakh M, Abo-Setta A. Characterisation and objective monitoring of balance disorders following head trauma, using videonystagmography. J Laryngol Otol. Jan 2012;126(1):26-33.
Dr. Cara Troutman-Enseki has no relevant relationships with proprietary entities producing health care goods or services.
Dr. Kelly Anderson has financial interests with the following proprietary entity or entities producing health care goods or services as indicated below:
- Other: Impact - Speaker on medication management of concussion
Dr. Anne Mucha has financial interests with the following proprietary entity or entities producing health care goods or services as indicated below:
- CE Speakers’ Bureau: Impact Applications
The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The University of Pittsburgh School of Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Each physician should only claim credit commensurate with the extent of their participation in the activity. Other health care professionals are awarded (0.1) continuing education units (CEU) which are equivalent to 1.0 contact hour.
For your credit transcript, please access our website 4 weeks post-completion at http://ccehs.upmc.edu and follow the link to the Credit Transcript page. If you do not provide the last 5 digits of your SSN on the next page you will not be able to access a CME credit transcript. Providing your SSN is voluntary.
Release Date: 4/4/2014 | Last Modified On: 4/4/2014 | Expires: 4/4/2015
Transcripts - Dr. Troutman-Enseki
So what do I hope that you gain out of this lecture? The 2 objectives for this lecture I hope that by the end of it you’ll be able to understand our model, our 5 stages of exertion, and in turn use those 5 stages to create an exercise program for your individual patients.
So why do exertion therapy, why not just have your athletes go work out on their own, work out with their team? The problem with that is we don’t know what they’re doing. Exertion means something different to every different person. We found that a lot of athletes would come back and say oh I ran up and down the field that’s enough, I’m fine, no symptoms. Or I worked out with my team, but you don’t know if it’s just a run through practice for football or if they’re actually doing something or if they’re just walking through. So we realize the need that we needed to have more standardized approach to kind of make sure each athlete was being stressed appropriately and one athlete wasn’t doing more than the other. It also falls into the return to play criteria so part of our return to play criteria states that the athlete must be symptom free with both physical and cognitive exertion.
Now one of the hardest things I had a problem with when I started with the concussion program is I went to Pitt, everything was evidence based, evidence based. But when I started doing exertion therapies there’s no evidence, I had nothing to go off of. I’ve kind of had to use experience as my guide and the little stuff that I had to go off of. In these 2 studies actually show the negative effects of exertion. The first one shows that student athletes that engaged in high levels of physical exertion following a concussion actually had worsened neurocognitive data, increased symptoms and longer recovery times. This suggests to us that we need to have more of a systematic approach to make sure that these athletes are carefully monitored and they’re not pushed too hard in the beginning but also so they’re not pushed too little.
And the second study that just came out this past February I believe, showed that in post concussive patients after they exerted and took neurocognitive tests, their scores actually decreased even though they said that they were symptom free. So this also kind of gives us a need for making sure that we’re exerting these patients once they’re symptom free prior to neurocognitive testing to make sure there isn’t a decline in scores.
So what is our model for the 5 stages of exertion? We’ll talk a little bit about our old model first. Our old model relied completely on heart rate, so we looked at the Karvonen formula, calculated the heart rate max based on the patients age and resting heart rate and progressed them through the stages. So for example stage 1 would be 20-30% of heart rate max progressing all the way to stage 5 which was max exertion. We used this model for the first year or two that we started out with exertion therapy, but the more I worked with patients as everyone said, we see thousands in the clinic a year, I kind of found that it wasn’t really a heart rate model. My patients could do max exertion on the stationary bike for 25 minutes but as soon as I would take them off the bike and they would try to do a squat or a lunge they would become completely symptomatic. So talking amongst ourselves with Ann, Mickey we kind of realized that there was more of a vestibular problem as you’ve heard multiple talks before me. So we kind of moved away from the heart rate model and kind of focused more on the stages by movement. So each stage progresses the athlete by movement incorporating more dynamic movements into each stage.
So now I’m going to go through our model of the 5 stages of exertion. So stage 1, stage 1 exertion therapy in our clinic consists of light aerobic conditioning, balance activities, exercises that limit head movement, so this is where you can still work them out, you can do stretching, you can do weight machines, you can do squats and lunges with focusing so you can have them perform a squat staring off into the horizon, focusing on an object so they’re limiting their head movement, still allowing them to do some activities. And this varied greatly from our old model because our old model in stage 1 they really weren’t doing a whole lot of anything and we were cutting them off once they reached that 20-30% heart rate max. Stage 1 through stage 5 I’ll always do core exercises so my stage 1 core exercises might consist of planks, side planks, 6 inches. Recommendations in this stage-exercise in a quiet area, this might be the patients that Ann was talking about with the face and motion discomfort. We have 2 gyms in our clinic, we have a smaller gym and a larger gym and these are the patients I would have in the smaller gym to limit the vestibular stimuli so they’re not getting too symptomatic early on. No impact activities in this stage because the quick up and down really makes them symptomatic. This is where they’ll usually be seeing Ann along with myself, so that the balance in vestibular treatment is by a specialist in this case, so they might be seeing Ann in the morning and come to see me afterwards in the afternoon. In this stage you really want to stress limiting the head and positional change and limit concentration activities in this stage.
Moving onto stage 2, stage 2 consists of light to moderate aerobic conditioning, balance activities with head movement. So this is where you can really get sport specific as you see in the photo I have a hockey player single leg stance while stick handling. So we’re incorporating a little bit more visual tracking and head movement in these stages. With the strengthening exercises now you might add head turns so some examples of that are side stepping with a band, with a head turn. They might do a side lunge with a head turn. Low intensity sport specific activities, so you saw the balance you can do that. Up in the corner we have the slide board for hockey players so starting that movement that’s going to get them back into their activity. Core exercises now will incorporate head movement so side planks with a upper arm head rotation so they are turning, looking as they are performing their core exercise or Russian twist which is a lot of head movement, you might have to start off slowly and have them slowly track a ball as they are doing their twist, but then you are going to kind of progress the speed as they get better.
Recommendations in this stage: this is where I would move them into our larger gym, kind of challenge them a little bit, expose the system, make sure that they are not getting symptomatic as they go into busier environments. Use various equipment, so now we are getting away from just the weight machine, we are trying to get a little bit more dynamic so we’ll use dumbbells, kettle bells, medicine balls, whatever you have in your clinic and allow for positional changes in head movement. This stage is where you might start some low concentration activities such as counting repetitions because you want to challenge both the cognitive and exertional systems at the same time.
Moving on to stage 3, so this is moderately aggressive aerobic exercises. This is where you might have them do intervals, stair climbing, pyramids, all forms of strength exercises. Stage 3 is where I’ll incorporate dynamic warmups, so carioca, side sashays, (inaudible), whatever you guys do for dynamic warmup. So this is the stage where I’ll incorporate that. Stage 3 is where I also incorporate impact activities, so running, plyometrics and agility drills. You’ll also really challenge the positional changes in the stage. Some great exercises I personally found are burpees or up-down where they do a quick jump, come down, push up, jump, it’s great for positional change and mountain climbers. You’ll have a lot of people that won’t be symptomatic so you’ll try these two exercises and they’ll suddenly get symptomatic so you know that they are not 100% yet. And then moving on to more aggressive sports specific exercises in this stage.
Recommendations, any environment is okay, so indoor and outdoor. Integrate strength, conditioning and balance/proprioceptive exercise and now you are going to incorporate concentration challenges. At our clinic we have MRS equipment which is just a leg press with a video screen so they can do games so they are concentrating on the game as they are doing a leg press. But you don’t need fancy equipment to do any of this stuff. One of my aids actually thought of a clock lunge which is an awesome idea. So you have the patient imagine the face of a clock and then you call out a number from 1 to 12 and they have to turn, jump, lunge into that position so they are thinking about stuff as they are doing movement exertion exercises.
Stage 4, so stage 4 is max exertion, all activity is just avoiding contact. This is where I’ll have the patient attend a noncontact practice, so they might be hockey, football, cheerleading, whatever they do they are going to attend a noncontact practice in this stage to make sure that they are okay.
And then moving on to stage 5, stage 5 is exactly the same as 4 except now you are going to initiate contact. So that’s the only thing that separates 4 and 5 in our model is the aspect of contact.
So when do you initiate exertion therapy? This is the million dollar question and as everyone has kind of alluded to there is no cookie cutter answer to this question. You don’t say in 2 weeks we are going to start exertion therapy. Every patient is different, so you have to go based on their individual presentation. So we initiate exertion therapy in many different situations, the first one being initiated in athletes with minimal to no symptoms. This might be the kid that gets a concussion at a football game Friday night, Sunday and Monday he has no symptoms, we might exert them there. Or this might be the patient that symptoms cleared up over a week or two, then we are going to initiate it. But it’s also initiated in athletes that are still symptomatic but have crossed over to that chronic stage of concussion management. These are the ones we want to get going, they’ve been sitting around doing nothing, symptoms really haven’t changed. They’ve tried medication, they’ve done vestibular and everything is kind of stale so we might kind of push them a little bit to keep them going, get them moving in the right direction.
It’s also as Kelly and Ann talked about, we initiate it earlier on an anxious and depressed patient, when someone is sitting around in a room doing nothing it increases their anxiety and depression so these are the patients we want to catch early on and get them going, get them towards their goal, so kind of relieve some of those psychological symptoms to kind of get them symptom free. It’s also initiated earlier in the migraine suffering patients as we know research shows that migraine suffering patients do well with exercise. This helps decrease the symptoms, so we want to kind of start these people off earlier to kind of diminish some of the headaches and dizziness.
And as everyone has mentioned numerous times, the timing of everything is it’s really a group effort. We all talk amongst ourselves, so Ann and Kelly and Mickey will all talk and say hey this kid needs to get moving, let’s go send him down to Cara. So then it’s really a group effort so that’s why we really don’t use a cookie cutter approach to everything.
Now our evaluation for exertion, I’m going to just highlight the key topics, this is another lecture in itself. It took me 3 hours to do it for our residents so I’m just going to go over a little bit of what we do for our actual evaluation. So the exertion evaluation is performed at the onset of symptoms. If the patient is not symptom free they must perform the exertion evaluation again before I say that they are cleared from exertion therapy.
The hardest part about exertion is everything is subjective. So we don’t have a lot of objective measures, it’s not like a knee or a hip where I can measure range of motion, test strength, so we are really going off of subjective kind of measurements with these athletes. So I’ll have them write their symptoms pre and post exertion and the scale that we use is based on of ImPACT. So that’s where the 0 to 6, everything I’ve ever done in my life is 0 to 10 but once I came into concussion it’s 0 to 6. So 0 means no symptoms and 6 is the worst it can be, meaning I have to go to the hospital, with 3 as our midline. So they’ll go through and rate headaches, nausea, lightheadedness, dizziness, mental fatigue and mental fogginess. They’ll rate is pre and post exertion, so we know if there’s a change, sometimes it might be an increase but other times there might be a decrease in symptoms.
We also screen for potential involvement of outside symptoms. As everyone in this room knows there is many different causes of dizziness, many different causes of headaches so we really want to cover all our boundaries and make sure that we check all these symptoms so we are not missing anything. The first thing we’ll look for is orthostatic hypotension, that can cause dizziness, lightheadedness, so can a concussion so we want to make sure that that’s not some of – causing some of their symptoms. A huge topic is cervical involvement. All my patients when they come to me they get screened for cervical involvement even though they probably already have been screened by Kelly, Dr. Collins, but I want to make sure myself just to make sure I’m not missing anything so I’ll look at active range of motion, I’ll measure it to make sure it’s within normal limits, I’ll do C2 kick test and Sharp-Purser test to make sure there is no instability in the cervical spine, and then I’ll also palpate the cervical spine and test mobility in the supine position. If there is some involvement I’ll treat it. I’m an orthopedic therapist so I will go ahead and treat those impairments.
We also screen for vestibular. It sounds like overkill but many times a patient might be fine when they go through Dr. Collins and I just want to make sure that we are not missing anything with the vestibular system. I also like to make sure that I know what’s going on with the vestibular system too because that helps me create my exercise programs.
And for the exertion evaluation we also look at the BESS test as Ann talked about, and I do the BESS test pre and post exertion.
After all of that has been cleared, after we’ve checked everything, got their symptoms we move on to the actual meat and potatoes of the evaluation. The first part is cardiovascular assessment, so they’ll perform 25 minutes of cardiovascular activity. Now I determine the cardiovascular activity based on what they come in presenting with. If they have an abnormal vestibular exam and reporting high symptoms they are going to start on the bike. I’m not going to start them on the treadmill or the elliptical because that’s just going to exacerbate their symptoms. Now on the flip side of it if they are coming in reporting minimal symptoms, have a normal vestibular screen I might start them on the elliptical or the treadmill because I know that they can handle it.
After the cardiovascular portion of the exam we go through the dynamic and functional testing. Now this consists of many different movements in both static and dynamic positions to kind of challenge the vestibular system. When we made this evaluation we talked amongst ourselves about all the key exercises that included all the key components of the vestibular system. We wanted to make sure we didn’t miss anything so that if an athlete came in and didn’t have vestibular therapy and just went through my evaluation we would pick-up on anything that could potentially be wrong.
Now if they pass this whole evaluation we’ll move into sports specific activities. Now this is where it varies based on the individual. So a hockey player you are going to focus more on hockey stuff or a gymnast you might have them do stunting, tumbling, whatever they are going back to and this kind of gives you free rein as a physical therapist to kind of decide what the pieces that you feel are important for this athlete.
So how do you determine the stage of exertion? So after you’ve completed the entire evaluation you kind of determine their stage based on how they did. If they made it through the cardio but then the more dynamic movements kind of flared them up, they weren’t feeling too good you had to cut off the evaluation before they got to the functional testing you’ll put them in an earlier stage. So this might be your stage 1, stage 2 patients. Now if they made it through the entire evaluation feeling pretty good, just minimal symptoms this is where they’d get a higher stage, stage 3, stage 4. It’s all based on how they presented in that evaluation.
The most important part of the evaluation is that second visit. This is where you are going to gain all your information. You are going to ask them how did you feel after you left? A lot of times someone might be okay when they are done with you but an hour after they left they had an intense headache, they felt nauseous, they felt dizzy, it lasted into the next day; this is the key to myself that I have to back them down a little bit and not push them so hard. But on the flip side of it you might have an athlete that came in that said I felt great, there is no problems so then you know to yourself hey I can push them a little bit harder. You also want to inquire to them about their recovery time, this is extremely important with exertion therapy. So a patient might go home, might have symptoms for an hour, they might have a headache but you need to educate them that’s okay, you are going to get symptoms, you want to look at how long it takes for those symptoms to go away. We don’t want to see the symptoms going and lasting into the next day, but if they are an hour or two after they leave I’m okay with that. And what you want to set your goals at is the more you see them, see their recovery time decrease. So that’s a positive experience. That’s working towards your goal as that recovery time decreases we are looking at that and that’s a key to us that they are actually improving, they are getting better.
And each individual’s program is tailored to the individual, so you might have two hockey players, they are not going to have the same program. Each of those hockey players is going to come in and present with different impairments. Someone might have problems with vertical movements where the other one might have space and motion discomfort. So even though it’s hockey you are going to tailor that program to what that individual presents with.
And the last thing I’m going to go over today is I’m going to take you through a sport specific example; but I would like to say that this is just a general example. I chose to do cheerleading because we talked endlessly about football yesterday and I wanted to represent the female population a little bit too. So I did choose cheerleading just to change the tone a little bit. But just as I said about the hockey players you can have two different cheerleaders but you want to focus more on what that individual is presenting with. So this is a general example, take it with a grain of salt, but I wanted to be comprehensive in my example.
Okay, so exertion therapy following the 5 stages that we use for a cheerleader. So in stage 1 this is where the patient might be instructed to perform the program 2 to 3 days a week in a quiet environment so this is where they are symptomatic, this is where you are going to want to limit the visual stimuli, you are going to want to limit setting them off but you want to slowly and safely expose them to some exercise. Cardio in this stage might consist of the bike or treadmill walking, core exercises limiting the head movement, so planks, side planks, flutter kicks. Balance in this stage you might have them do single leg stance and tandem stance on the foam, eyes open, eyes closed; stretches, so you can still get sports specific in your stretches. So cheerleading has a lot of stunting, tumbling, they have a lot of wrist injuries so this is a great stretch for cheerleading specific, so wrist flexor extensor stretches. So you can see in the corner splits, they love this. They are in stage 1, they are symptomatic but they can do a split and they are so happy because they are working towards their goal or working towards what they are going to, we are not just doing random exercises, we are working towards what do I have to get back to so just allowing a cheerleader to do a split you’ll see the biggest smile because they’ll get so excited that they are actually doing something they are going back to. I won’t go into detail but I wanted to be comprehensive so these are other stretches specific for cheerleading. And I should say I did a lot of research on this. I was a cheerleader so this one was easy, but I do do every sport so I had to do a lot of research into each sport of what’s appropriate for each sport.
Strengthening in stage 1, so minimizing head movements in stage 1. So these are some examples of strengthening exercises that you might see in stage 1, so wall sits, Bosu weight shifts, Bosu squats, lunges, biceps curls, simple but still allowing them to do movements. Triceps dips, wall sits with biceps curls, just still in strengthening, still stage 1, very different than our old stage 1 based on the heart rate model, they wouldn’t be able to do any of this stuff after cardio because they’d be shut down.
Moving on to stage 2, so stage 2 we are incorporating movement. This is the stage where we are allowing them to be exposed a little bit more to movement. Now we are adding on a workout day, so they may be instructed to perform the exercises 3 to 4 days a week in a gym so we want to stress the vestibular system, we are putting them in a gym now, they are not in a quiet environment. Cardio might consist of 20 to 25 minutes of stationary bike level 5-6 resistance. Now with the core exercises we are adding movements. This might be where we might incorporate the Russian twist. We might do planks with leg extensions, hollow hold. Now we are getting even more sports specific so their single leg stance now has become doing what they have to go back to so scale on foam, liberty on foam, heel stretch on foam and really making it sports specific, really different than the picture I showed before of the hockey player doing stick handling. So that just shows you how you can individualize these programs based on sport.
With the strengthening you are adding more dynamic movements, so backward lunges, hamstring curls on Physioball, sidestepping with a band, once they can do, fine, that you’ll add sidestepping with a band with a head turn. So now you are adding the head turn movement. Pushups, pushups are a great exercise. The last student I had actually thought of a great one for convergence problems, pushups looking up and down, alternating, so you are getting that real quick near to far. So that’s another good exercise to kind of challenge that. The type of exercise is great for a base in cheerleading because they are getting that real quick up and down movement with the medicine ball which adds the weight component of what they have to go back to, they have to go back to lifting their partners, so you are working on that in the clinic.
Moving on to stage 3, so now the patient is instructed to perform the program 4 to 5 days a week in any environment. Cardio might be 25 to 30 minutes of the stationary bike or elliptical, now this is the stage where we talked about we will add that dynamic warmup. For a cheerleader you might do walking with arm circles, toe touches, jumping jacks, knee hugs, carioca, side sashays, whatever they need to do. Your core exercises become more complicated so V-ups, planks with oblique twists, knees to chest on Physioball.
Now we add the height component to the balance, so it wouldn’t do cheerleading justice if you were just going to have a flyer go back after practicing single leg stance, so now you are going to add the height component. I’ll have them perform the scales, liberties, heel stretches on a platform now to make sure that they don’t get symptomatic once that height component is added. Strengthening even more dynamic so walking with lunges, so now you are walking with the lunges, you can add a head turn side to side, squats on disc with weights, medicine ball overhead throws in a basing stance and as I talked about earlier this is where you would add the plyometrics, the mountain climbers, 2 hurdle quick step for agility, bounding squat jumps. Trampoline, trampoline is a great exercise to challenge the vestibular system so trampoline exercises, jumps, high knees, turns, you’ve got that real quick up and down movement so that’s a great tool to make sure that they don’t get symptomatic.
I will not clear a cheerleader without doing two important things, one is jumping and then you’ll see in stage 4 the other is tumbling. So jumping, they must perform all these jumps and we don’t just perform one of each, we do them in unison so they will do multiple repetitions of these jumps. So I’ll make them do everything that they have to go back to, tucks, toe touch, hurkey, hurdler.
Moving on to stage 4, so now they are instructed to perform the program 5 days a week in any environment. They are instructed to perform their dance routines and cheers at cheerleading practice, so this is where you incorporate that noncontact practice. Cardio might be 30 minutes of spin intervals, elliptical or treadmill jogging, core exercises might be V-ups with medicine ball, flutter kicks with medicine ball toss and side planks with rows. This is a tumbling series, so if they have accomplished these feats prior to obtaining a concussion they must do them before I clear them. So if they have their back hand spring they are doing it before they are cleared; before I tell Mickey that they are okay to go. So we will go over, we are lucky in our clinic we have a Plyometric floor so we’ll use that floor and we’ll go over cartwheels, round offs, back handsprings, front handsprings and back tucks. Jumps in series now, so they might do split lunge jumps, they might do knee to chest with medicine ball. Box jumps and depth jumps, we’ll do all these in the stage 4 to make sure that they are not symptomatic.
Agility drills in this stage we do have a stairwell in our clinic but we also have it across the field, we are allowed to use the Steelers’ indoor practice field so I might have them do running stairs. So stair workouts, they might do for example forward 2 feet, side stepping with right and left leg leading, every 2 steps, single leg bounds and they might do jumping rope. Some of the examples of some of the jump rope work routines are high knees, skipping, 2 feet hops and single leg hops.
And then the last stage moving on to stage 5, so now the cheerleader is instructed to perform the program 5 days a week in any environment. Once they are cleared by neuropsychology they can return to contact, they’ll go back to tumbling and stunting with their teammates and you want to really make sure that their dry land drills are high intensity interval drills to challenge the patient’s anaerobic exercise threshold and the cardio in stage 5 might consist of 25 to 30 minutes of jogging, sprinting intervals and running stair circuits.
And before I conclude one of the questions that I was asked last night was why cheerleading? I just want to say that I’ve had just as many cheerleaders as football players this year so that it is an injury that’s highly prevalent in cheerleaders as well. Thank you.
Transcripts - Dr. Anderson
So I’m going to talk about the medical management, I have 30 minutes to talk about everything I do. I could probably spend the whole day trying to explain how we do this but I’m going to try to be brief here for you but explain it all. My objective today is to help you to identify and medical manage post-concussion syndrome in the areas of sleep dysregulation, headaches, cognitive difficulties and mood disorders.
Some of the limitations I wanted to first and foremost start with are that there are no FDA approved medications for post-concussion syndrome. When I meet with a patient or their families what I say to them is no medication that we talk about today is going to cure your concussion, what it’s going to do is it’s going to help facilitate your recovery, it’s going to help those symptoms so that you are able to get through this process a little bit easier. Research is limited on the subject of medications with regards to concussion and so that’s an area that I’d like to get further invested in. Also post-concussion syndrome, it is a multifactorial issue and symptoms can be difficult to manage at times but one of the biggest things is just to sit back and don’t get frustrated, utilize your colleagues. I’m sending emails to my therapists, to my neuropsychologists, talking to them on the phone because again it is a multifactorial approach and without their input I wouldn’t be able to do my job as best as I could.
So the four areas that I tend to look at, I come into play about 3 or weeks or so into the injury when you know the rest is just not enough and the symptoms to be a little bit overbearing. So I look at four specific areas, neuropsychiatric where we are dealing with a lot of emotion, sadness, nervousness, irritability, they feel out of control with this injury; I look at the physical symptoms including headaches, visual disturbances, dizziness, latent noise sensitivity and even ringing in the ears, nausea; we look at the sleep dysregulation, there is a significant sleep disturbance with concussion, either people are having difficulty falling asleep, maybe staying asleep, they are waking up a couple of times during the evening or they are just sleeping too much or too little; and then finally we look at the cognitive symptoms, attention and focus difficulties, memory dysfunction, that’s a very big frustration for our parents – or our patients, fogginess that big word we always talk about, fatigue and then just kind of just slowing, they just feel slower than usual, they even tell me you know I really feel stupid, I just don’t feel like I’m working at the level I should be.
So first and foremost if I cannot get them to sleep, their symptoms are going to be difficult to manage and so again like I said we have issues with sleep dysregulation in terms of sleep initiation, maintenance, too much, too little sleep. Some of the issues and the – what we’ll find is – some of the possible etiologies for sleep dysregulation they may come in and already have trouble sleeping so you are kind of starting from behind the boat there. They may have headaches that are keeping them up at night or when they wake-up to go to the bathroom you know they are like I still have this headache, I can’t get back to sleep. Environmental stimuli is a big thing, don’t allow the kids to go to bed with the TV on or their phones next to them. Music playing sometimes can be a plus or a minus. And then some pharmacologic effects, maybe the medications that they are already on are creating some insomnia, or even maybe the medications I’m starting them on are worsening that so we have to take that into consideration. Also anxiety and depression whether they’ve come in with some of those emotional aspects or the concussion has brought that out, anxiety and depression we know can cause hypo or hyper insomnia.
So treatment, first and foremost I am the medication lady in the group, however if I don’t have to start a medication I’m even happier. So we’ll start with behavioral strategies which our neuropsychologist and vestibular and exertional therapists will back me up on. We work on proper sleep hygiene. Again, limit that TV, the computer use, the phone, remove I-Pads and I-Pods at night. You really don’t want that distraction, those kids are sneaky so be careful. We work on relaxation therapies, whether it is putting a little bit of a slight spa like noise in the background, you know water falling, sometimes I’ll have them turn on a fan to create a little bit of white noise or just having them lay down, put some heat behind their neck, have them relax their scalp, relax their forehead, relax their cheeks and on down to their toes, just sone easy techniques. But the biggest thing is sleep restriction. We have got to get those sleep cycles in check. I tell them no more and no less than 7 to 9 hours. I don’t want you napping and that’s where I get flack back from those students but napping just interrupts the body’s natural sleep cycle and that just really makes this difficult.
So next we are going to talk about if these behavioral strategies aren’t helpful for them then we are getting into some pharmacology. First I want to remind the body you know that it’s nighttime, and so we’ll try the melatonin agonist first. I typically start with 3 to 5 mg. Your body does not need a lot of melatonin so they should respond to these lower levels, regular versus extended release. Some of the pharmacies will carry the extended version and what that will – what I’ll use that for is if they are having trouble staying asleep throughout the night. If they do wakeup in the middle of the night and they are taking a low dose it’s okay to start to take another tab about 3 to 4 hours later. Antidepressants, in the field PCPs will use some of these medications just as a sleep aid initially. Amitriptyline is good and I use that especially if there is a headache component, we’ll titrate up usually to about 30 mg. Trazodone is another good one. I start with 50 and increase to 100 mg. And this is if sleep is just the issue. You do want to monitor side effects in these, you are starting antidepressants. And men in particular they like to be aware that there is a possibility of priapism, so that’s something to mention.
If there is a sleep issue and it’s intermittent, you know they are having trouble getting that sleep cycle back I will use those non-benzodiazepine hypnotics like Ambien or Lunesta. Typically I’ll try Ambien and this does have an addictive potential so you want to be careful with it but in the short term I tell them you know we just need to get that sleep cycle back on track so we’ll use it for maybe 1 to 2 weeks to regulate that cycle and then just use it as needed. But make them aware of some of the vivid dreams they might have with those. Antihistamines, I’m not so afraid to use those in children especially because that helps them fall asleep. You can even tell them they can try Benadryl to just for the next week get that cycle back on track. I included some of the dosages of the medicines that I use in case you need those.
So next we are going to talk about the somatic symptoms. Many patients are going to experience headaches, dizziness, nausea, latent noise sensitivity, tinnitus which is a very frustrating issue. Tell them that it likely will get better. I have a few patients however that are kind of getting used to their ringing in the ears now. These are important things to let patients know. A lot of them will experience this. Make sure that they realize that they are not alone in these symptoms.
I want to first talk about dizziness because this is a big frustration for our patients. Dizziness and we have found and Mickey’s talked about it in previous discussions that patients with protracted recovery from concussion frequently have dysfunction in the vestibular system. What I’ll do is I’ll see them a couple of weeks possibly after the neuropsychologists have evaluated them so I’m doing my own evaluation in terms of a gross vestibular exam. We are doing the gaze stability and the VOR, the accommodation/convergence because maybe they’ve allowed them to go back to school a little bit and that increased stimulation has brought out that vestibular dysfunction. And so I’ll talk about that with them and then speak with the neuropsychologist again and we may get them into that vestibular evaluation.
The vestibular therapy of course is the mainstay of therapy and Dr. Mucha will talk a little bit about that in a little. This can be central or peripheral. One thing that I like to kind of help out with is if I feel that there is a positional component to their vestibular dysfunction as in the BPPV, the benign paroxysmal positional vertical, it’s a transient vertigo, they’ll talk about it you know as I go to lay down and turn my head from side to side on the pillow I’ll feel significant dizziness. You can do this easy exam in the office, Dix-Hallpike maneuver where you are assessing the posterior, anterior and horizontal aspects. You do the Epley maneuvers to fix that in the office or I’ll have my vestibular therapist make sure that they assess and treat that as well. But it’s a quick easy test you can evaluate in the office.
Headaches, this is possibly the bane of my existence but it is a – it’s also a challenge which makes it exciting to try to figure out. Most commonly reported symptom of concussion they talked about earlier yesterday that 70% of concussed athletes may experience headaches. The important thing to note is it may not develop right after the injury, it may come out a couple of days later so make patients aware of that. And often as we’ve noted before it’s worsened with physical or cognitive exertion.
So somatic symptoms, again we’re going to go through the differential of headaches. We may experience rebound headaches, patients may be self medicating with ibuprofen or acetaminophen and so we need to make sure we’re assessing rebound. Musculoskeletal or cervicogenic, often times these injuries come with a whiplash effect and they’re having myofascial or tension related headaches, facet tenderness even. They could even have some injury to the greater occipital nerve and be experiencing nerve related injury. Post traumatic migraines which we’ll talk a lot about. And then there’s cognitive fatigue related headaches that as the brain is stimulated throughout the day it gets tired and then you result with a headache.
The rebound headaches are what I want to talk about first because if you’re not assessing that it’s going to drive you crazy when you find out they’ve been taking ibuprofen everyday. Medication overuse is such a big issue. Rebound headaches - the most common causes of those headaches are opioids. So they’re feeling like those narcotics are working for their headaches, tell them that it’s going to develop into a chronic issue. The Butalbital containing combination analgesics are also one of the most common, and then the aspirin, acetaminophen, caffeine or the Excedrin migraine type medications are a big offender. In particular the opiates, I want to make sure that you guys realize the importance of avoiding these in headaches is because there is that huge risk of transition from the episodic headache to the chronic headache. It’s actually even more of an increased risk in men who are using those medications greater than 8 days out of the month. So you can tell your patients yeah I know that you feel like this is working but it’s going to be very detrimental to you actually. Acetaminophen of note has a greater risk of rebound headaches than NSAIDS and the triptans. And just again, I know that they want that brief relief but tell them that in the long run it’s going to be better not to take those medications.
Let’s talk briefly about the musculoskeletal, the cervicogenic component. You’re going to be looking at that in the office as well or the physical therapists are going to be dealing with this. I’ll often do my assessment in the office and if there’s a cervicogenic component I’ll send them for physical therapy. They’ll work on range of motion, modalities, ultrasound has been great, massage and traction. I’ll also actually even send them home with a TENS unit myself if that seems to be helpful in PT. We will occasionally use pain relievers and muscle relaxants but you want to use those sparingly especially muscle relaxants mainly at night because the drowsing effect. Occasionally if we find occipital or cervical paraspinal trigger points we’ll do trigger point injections which can create some relief. The nerve blocks, I use those sparingly, but if you’re hitting a wall and you realize that this may be a greater occipital neuralgia issue then go ahead and send them for those. Again, relaxation techniques, biofeedback, and then ultimately some patients like to try acupuncture and I’m okay with that.
The post traumatic migraines, the big issue that we like to talk about here because it is, I mean if people are coming in with migraine headaches, it just, it makes the recovery a lot more difficult and therefore, I think that medications play a huge role in this. So the post traumatic migraines – ask about personal history, ask about family history that sets them up, it kind of lowers that threshold for them to have post traumatic headaches. It’s when they have a headache throughout the day, usually it’s unilateral behind the eyes, there’s light or noise sensitivity, nausea, dizziness, we’ve talked about the vestibular migraines, so if you notice that they’re really, they’re just having daily headaches, they go to bed with a headache, they wake up with a headache, I’m typically trying to, I’m going to initiate a medication most likely. But again, I like to, if I don’t have to prescribe I won’t, so we’ll try behavioral modifications like working on sleep, nutrition, hydration, stress control and exercise. If they hit all those areas and work hard at it, they can cure their own headaches so that’s what you want to stress.
Vitamin supplementation, that’s also been shown in some randomized control trials to decrease the migraine frequency with chronic supplementation. So I’ll tell them for the next 3 months I want you to take these meds daily, and I’ll either initiate it at the beginning or if I’ve tried all kinds of different treatments and nothing seems to be working, I’ll add that in. Here’s some of the dosages. The main 2 that I use will be magnesium oxide and riboflavin, but if they’re willing to take other vitamins and increase their pill count we try the Omega threes, Coenzymes Q-10 and then the ALA.
If their headaches are occurring maybe once a week and it’s just getting to a point where they can tell that that headache is going to come on, it’s going to reach migraine potential but I’m not afraid to use the abortive medications like Imitrex or Maxalt, the triptans. I use them sparingly. I ask them, you know use this when you know it’s going to be that headache that’s going to send you to the emergency room for the migraine cocktail and typically those patients, they’ll know when that headache is coming on. I’ll use either of the triptans, you can use whatever you like best, but I definitely like to use the lowest effective dose, so I’ll have them start usually at 25 mg of the Imitrex and titrate up as they need. Same goes with the Maxalt but again, limit the use because these can create rebound headaches as well.
Alright, so post traumatic migraines, if they’re occurring greater or equal to 2-3 times during the week and it’s included with sleep dysregulation, nothing seems to be working for these headaches then I’m going to use a preventative medication. I try to avoid it because it does have a higher side effect profile, but it is very much a part of my treatment regimen. This is kind of a busy slide but it’s the medicines I use for post traumatic migraines, so write them down, highlight. They are a great tool in helping these patients. Typically what I’ll go to first for preventative medications from a pharmacologic standpoint is Amitriptyline, that is my golden medication mainly because it’s number one side effect is drowsiness and often times with headaches I’ll have issues with sleep. I titrate up from 10 mg every 3 days to 20 mg for 3 days and then ultimately 30. In some cases I will go up to 50 but I don’t go any higher than that. Parents and patients will get nervous when you say that it’s an antidepressant but make sure that they know you’re using lower doses. Antidepressant dosages are up in the 100s, 150s, 200s and it’s just an excellent medication for migraine prevention. IN some cases if there’s a mood issue involved as well, we’ll use the Venlafaxine or the Lexapro or the Zoloft. The headaches, those migraine headaches could be triggered by the anxiety or depression so make sure you’re aware of that. Anticonvulsants I try to limit, however, they are a great medication for migraine headaches. The Topiramates I have had some higher side effects on that so I try to avoid it but it again, if you need it, you need it. Especially in the dancers who are worried about weight gain, Topiramates for migraines are a good choice. Depakote is also used and then Gabapentin, I rarely use this unless there’s a true nerve involvement. I don’t get good relief from Gabapentin unless it’s that occipital neuralgia type of a headache, and then beta blockers which of course you have to be careful in your NCAA or NFL or professional athletes because it is on the restricted list. Also in patients of course, whose blood pressure is an issue that’s always a good addition if you need a migraine medication.
When I talk to people about starting a preventative medication I do say that this is kind of a commitment. It takes 4-6 weeks to see the maximal benefits of these medications so tell them yeah you’re going to, when we take this step you’re going to be on it for a couple months. I typically like to use it for about 4-6 months before pulling it off, and once they’re aware of that treatment plan they’re okay with it. But I definitely like to warn them of that.
And then cognitive symptoms, this is a big area for us. Often times patients are going to complain of that fogginess, it’s difficulty concentrating and focusing at school or at work, they have memory impairments, cognitive fatigue, what we say is that slow, thinking or processing. Patients feel just almost like a sense of loss of control, they just don’t feel like they’re able to produce the results that they normally do at work or at school. So this is very frustrating for them. The cognitive fatigue headache that you may hear us talk about is a headache that worsens as the day progresses. Typically in the morning they wake up, they’re feeling pretty good, they go into school or to work and by lunch time that headache is settling in and they’re just getting so tired. We found that medications that improve the dopaminergic transmission, helps that cognitive fatigue, it can improve long term functional outcomes that can facilitate recovery and increase the quality of life, it just makes them feel better which is what they want right now, they’re frustrated enough with this injury. So here’s one of the studies that UPMC Concussion Center performed and it’s about he efficacy of Amantadine treatment of symptoms and neurocognitive performance among adolescents following sports related concussion. The study involved a treatment group and a control group. Now the treatment group received 100 mg of Amantadine, 2x a day, there are 25 males and female adolescents and then control group was treated conservatively without the medication. These adolescents had not recovered within the 3 weeks with just the rest, the physical, cognitive rest and accommodations and then were started into the program. They checked the pre and the post treatment at 3-4 weeks neurocognitive and symptom assessments and what they found was that Amantadine was helpful, more helpful in the treatment group. The findings provided the initial support for the efficacy of Amantadine. Again the 200 mg a day, again it is not, it’s a treatment for the symptoms of concussion, it doesn’t cure it, but we have found great benefit. By the time the patients are seeing me that is one of the medications they’re likely to start. We do however, need a double blinded, randomized control trial of the efficacy of Amantadine to really give us a good, large sample to corroborate these findings, and hopefully we’ll be working on that and publishing that at some point.
Next I wanted to talk briefly about a case that proved the efficacy of Methylphenidate. Don’t be afraid to use some of the stronger stimulants. I always start with Amantadine, it has a less side effect profile, it’s not addictive, but these, the stronger neuro stimulants work as well. White et al, in 2004 conducted a double blind placebo controlled crossover trial of Methylphenidate. Thirty four moderate and server TBI out patients were used in this trial and the key findings show that there is a primary benefit on impaired processing and speed. It may also improve attention, memory, and higher demand cognitive tasks. The thing that I look at on the impact tests are the reaction time and the visual motor speed and if those are low then I’ll find that that stimulant is going to help them so that’s where kind of I can contribute to the impact scores. And they’ll alert me of that as well, which is helpful.
So don’t be afraid to use these neuro stimulants, it really does help the symptoms and you just see the personalities come back, because they’re feeling better, they feel that they’re processing speed is better, the reaction time is better, they feel more alert and are able to focus and concentrate. I have the majority of my patients will come back and say you know what after just starting that medication a couple days I felt more myself. It works on the dopamine receptors creates, alertness, the ability to focus and concentrate, gives the brain a little bit of an energy boost is what I tell them. I mean overall it just makes the body have a little bit more energy as well. Like I said I’ll use Amantadine first, 100 mg with breakfast for 5 days, then 100 mg with breakfast and lunch, it typically wears off 4-5 hours, so you want to make them aware of that. I have them take it with food because initially it may upset the stomach and create a little bit of nauseasness but that will go away. The number one side effect of this is a little bit of jitteriness so we ease it into the system by going once a day for 5 days first and that typically goes away. In rare cases I’ll have it do the opposite effect and create more fatigue so be aware of that. And then in my very, very type A anxious patients it may in crease their anxiety a little bit so you may want to titrate that a little slower or half the dose. I will also if needed, if Amantadine is not effective or not effective enough, I will try the Adderall, the Ritalins, the Concertas, the Stratteras if needed. Especially in patients who have a history of ADD or ADHD, what I’ll find is that and they’ve discussed before, that with concussion those focus and concentration issues are just exacerbated and so we will likely start them on something they may have previously been on. The other thing to note if someone has been on a neuro stimulant already for those issues and they’ve been on a dose for maybe you know steady 2-3 years, 5 years or so, I don’t hesitate to try Amantadine on top of that because they’re body is used to that dosage and if their cognitive symptoms are worsened I will add that in, just kind of a little side note there.
Finally neuropsychiatric symptoms, last but not least for sure because we’ll find that mood disturbances occur following concussion in many, many cases and these are my most complicated cases, Nickie can back be up on that. If there’s an anxiety, depression, even a post traumatic stress disorder component some of those symptoms will overlap with our post concussion syndrome and even prolong the recovery period. Patients will feel nervous, they’ll feel irritable, more irritable than normal, nausea, sleep disturbances, sadness, just hyperemotional. I’ll have patients where they’re like I never cried before but I’m crying here in your office and I’m like I do that to a lot of people it’s okay. But they just, they have that sense of loss of control and that is uncomfortable especially for you know athletes and people who are in the workforce, they just don’t like feeling out of control. We remove them from their social experiences and from the activities that they love, we try to get them back in quickly but it’s uncomfortable for them to be off of that normal routine. There’s also family stressors that may be going on and there’s even school stressors, kids are mean in school sometimes, we know that. And when you can’t see this injury, kids at school may make fun of them and say oh you’re just faking it, you know and so you need to be aware of that and counsel the parents on that as well to be looking for that because that leads to anxiety and depression in kids and even people in the workforce as well. The big thing is don’t forget to evaluate for clinical anxiety and depression and post traumatic stress disorder, get them into the services that may benefit them earlier. We’ll definitely have people who came in with undiagnosed anxiety and depression and finally they’re kind of admitting to that which is helpful in their treatment program.
First and foremost we try psychotherapy. If you’re in an area that you aren’t familiar with your therapist or psychologist, make sure that you get to know them because they’re a great resource and if you know a couple names that you know really work well with concussion patients then you’re going to want to give those as referrals because you send people out and you say you know you need to talk with a therapist, talk with your PCP. We’ve found that less people are really getting into those therapy sessions because that’s extra work for them or it’s difficult to find a referral so link in with a couple of the psychologists or therapists in your area.
Antidepressants I will use, definitely that’s part of my treatment regimen. Most of the time when they’re seeing me for the first time we’re not talking about this but if the issue has kind of gone and gone on and things aren’t getting better then we’re talking about SSRIs, TCAs or SNRIs. I hold off on the TCAs only if they have a headache component, but I use a lot of Lexapro and Zoloft in my regimen, those are just 2 that I’ve worked with frequently you can use whatever works for you. But in the patients where again they may have had an anxiety, depression disorder prior to this and it has worsened now this really will lift their spirits, it does work, so don’t be afraid to use it. Like I said the TCAs if there’s a headache and a sleep component that may be beneficial however, remember you’re using lower doses of that for headache and sleep so it may not be as effective for the anxiety/depression.
Benzodiazeapines, we always afraid of those, limit the use for sure but they do have a role in concussion management because in some cases you just need to treat that anxiety for the short term instead of going to an SSRI. Some patients may develop panic attacks, sleep disturbance because they can’t shut that mind off at night, they’re worried about what they’ve missed during that day, you know the future, am I always going to feel like this. So occasionally I will use Ativan or Klonopin at low doses. Again this can be addictive and you worry about the potential for selling this, you know drug seekers, but we don’t really get that in the concussion world which is wonderful, but I will use a little bit of Ativan or Klonopin at night. The other thing is, and Dr. Mucha will talk a little bit more about this in the vestibular talk, but when there’s a significant dizzy component these patients get anxious. If they’re in this crowded room, walking through the hallway, they’re going to probably set off a panic attack. In the grocery store, even on the bus, or in the hallways, that space and motion issue will take over and then that anxiety comes out and that’s actually where Klonopin can come into play and I use that twice a day. It’s been shown to decrease vestibular symptoms and improve the vestibular related anxiety so I’m not afraid to use that. I’ll be in communication with vestibular therapists and the neuropsychologists and we’ll decide you know if this is taking over we need to control that. The reason I choose Klonopin is because it has a longer term effect. It’s not in and out of the system like an Ativan or a Xanax might be. We don’t want it to go in waves, we want it just to settle out and kind of have that long term effect. So I’ll use .25 mg 2 times a day. In some patients who the dizziness is pretty significant during the daytime we’ll do it morning and early afternoon, but if there’s an issue with sleep and the mind won’t shut off at night then I’ll do it more towards the evening. They should not be on this medication for very long, a couple weeks, it supplements their vestibular therapy so as they’re finishing out with vestibular I’m usually starting to come off and actually Ann and I will talk a lot about interactions with patients and say okay I think we can kind of try to titrate this off or keep it on a little bit longer. Again that’s why I stress the team approach, communication is key in concussion recovery. But don’t be afraid to use these medications again it’s short term and they come off of them.
So again I kind of want to summarize with the four areas that I deal with, the emotions, the cognitive symptoms, the sleep disturbance, the somatic complaints, no 1 patient or 1 concussion is the same, you will find that out. It’s important for you to get information from the parents even from the athletic trainers in terms of the sports related concussions. It is a team approach, I can’t stress that enough. But these are the 4 areas patients may experience 1 of the 4 areas, others may experience all 4, just realize that they’re scared really and what your role in this as a physician or a medical provider is to treat some of those symptoms but again I want to stress that none of these medications are going to cure it, it is just going to make the process a lot easier for them. We try to avoid medications early in the concussion recovery process, but there is a role. When you’re talking to these parents and you’re talking about antidepressants, you’re talking about preventative migraine medications that these kids might be on for a little while, for a couple months, they’re concerned. So your job is to ease that level of anxiety in the family so that you can, you’re able to treat the kids, because they do get better. I do love what I do. It’s interesting because I have the ability to kind of be a part of their lives for short term but you make them feel so much better and you watch them go from you know this quite individual to seeing their personality come out and it’s enjoyable. So I really do love what I do.
What we do know though is that for sure this is definite that rest and reduced stress on the brain helps with recovery; cognitive rest with academic accommodations, physical rest, however, again don’t let them sit in a dark room that worsens the situation. We do know that sleep helps, again 7-9 hours, no more, no less, no naps. That’s like my mantra for the sleep issue. And then treat the symptoms, there are appropriate medications, there are appropriate therapies, get them into vestibular or the exertional rehabilitation if needed, and what we’re finding though is more research is needed and so that’s where we come into play. It is an exciting role to be on this team and I’ve appreciated all of the input. So questions we’ll take during the panel discussion. So thank you.
Transcripts - Dr. Mucha
So what I hope to accomplish is at lease, an I realize that some of you are clinicians in vestibular therapy so you won’t have as much to learn, but there are many people here who probably don’t know much about what we’re talking about with the vestibular system so I want to help to solidify the idea of what the vestibular system does in concussion and it’s relationship to recovery. What are the common things that we see after concussion that are involving the vestibular system and what is rehab and what does that entail, and what things are we doing.
So you saw this recovery graph yesterday and I think it’s a great illustration of what happens with concussion and we’re very lucky that with just rest alone or not messing things up, most of our patients are going to revery quickly. But there’s certainly this percentage this 1 in 5 perhaps that are not going getting better quickly and that counts for a significant amount of morbidity. A lot of lost time, a lot of lost work hours, a lot of strain in family life and how can we best identify who these folks are and perhaps intervene. So these are the common symptoms that we see following concussion. This is from a sample, a large sample of collegiate and high school athletes. Looking at the typical symptoms and of course number one is headache, which we all know and we talked about yesterday. But I think if you look down here on the list the things highlighted in red when we look at the dizziness, the fogginess perhaps which might kind of go between different systems, balance problems we know that this injury goes far beyond just the cognitive symptoms and the headaches, we know that it involves other parts of the brain. So I think we’ll talk a lot more about this conceptual idea these concussion trajectories, and I think at least from a standpoint of seeing about 15,000 plus patients in our clinics each year, we have started to figure out that there are similar presentation patterns that present in our patients post concussion. And I’m going talk about this vestibular trajectory that’s at the top. We’ll hear a lot more about the trajectories that are beyond; ocular motor problems, the cognitive fatigue headache issues, post traumatic migraines, cervicogenic anxiety, mood. And in reality none of these typically exists in isolation as you can imagine often and almost always there’s overlap among these different presentation patterns but I think that kind of putting them in these like groups has really helped us as a clinical program to figure out how to manage these conditions. And oh, and sorry and back to the vestibular trajectory, what we find is in these folks typically, these the patients that have the vestibular problems, we also find that there’s some things that we can identify from impact that usually help us to also put them in that category. And what you’ll usually see is that the folks that have vestibular issues are usually having problems with reaction time, and visual motor speed. So it kind of might make sense from a standpoint of where in the brain we’re talking about there being disruption.
This you also saw yesterday this is just kind of the again more evidence about why the vestibular system or that the vestibular system is implicated in these slow to recover folks. This is from I think Dr. Collins talked about it as well as Dr. Eldon in the afternoon, about how dizziness is the one on field predictor of slow to recover patients. So why is that and what does it mean and what do you do about it, so that’s what we tell everybody.
So let’s, I’m going to try not to bore you but just to give you an idea of the vestibular system and take you back, we’re talking about two components. We’re talking about the peripheral system which is the inner ear, the bony structure of the inner ear, which is a motion detector, much like your eyes is the visual system sensor. Well the inner ear is the vestibular system sensor, however, that is not all there is to it. And the most important part is the projection centrally to the brain stem area, the cerebellum, the vestibular nuclei, cortically, etc. So what we’re finding is that typically in our patients the labyrinth itself usually except in cases of BPPV and labyrinthine concussion is usually in tact however, it’s the central processing of the information that gets disrupted. And so just to kind of talk about dizziness as a construct, we typically think of dizziness as only being a vestibular system issue and as a vestibular therapist I probably am biased that way because it often is. And so the most common things that you’ll see that cause dizziness following concussion would be if we’re talking about things that affect the labyrinth it would be things such as benign positional vertigo, there could be a labyrinthine concussion which just as you can concuss the cortex, you can concuss the labyrinth itself and create disrupted functioning of one or both inner ears, perilymphatic fistula which again is probably something that you’ll see much more often in more severe brain injury but again it’s a condition involving the inner ear itself. But then the central issues which are affecting the central processing would be post traumatic migraine especially vestibular migraine and concussion to the brain stem structures. But we do have to be mindful that there are non-vestibular causes of dizziness and we have to evaluate those as well so that’s why we have evaluation of the ocular motor function. Some people will perceive their visual blurring as dizziness and so a very important thing to look at. Cervicogenic dizziness is kind of the wild card, it is a central processing issue. But it is certainly different than vestibular causes. And autonomic issues are also at play here sometimes. But I say definitely by and large most of the dizziness that we see clinically is because of these central vestibular issues.
This is just our reminder about the role of migraines and concussion and especially the role of migraines and dizziness as well. We know migraines clearly present headache issues and we know that those that experience post traumatic migraines are more, much more likely to be in the slow to recover group. We heard that in yesterday’s talks as well. But what we also need to know is that in general migraine is not just the headache component, and we know if we only look at migraine as a headache then we’re missing half the story. To diagnose a migraine we’re looking at headache with nausea, photophobia, photophobia of visual aura. However, there are variants, there are vestibular migraines, ocular migraines that are out there and what we know from the vestibular literature is that the dizziness and migraine are highly correlated and that’s because the migraines often affect the vestibular structures or the vestibular functioning. And just in studies we know that migraineurs have more dizziness than the regular population and in the regular population who have dizziness, many more of those are migraineurs. So it’s kind of an obvious correlation and the thing to note is that even people who know that they have migraines and never had dizziness as a presenting factor, that can change over time. It’s been well documented that the way that migraines present in people who are migraineurs can alter very significantly over time from being headache only, to being ocular, to being vestibular. Well what we’re finding is I think that in concussion that’s even accelerated a bit. We’re finding that again people even who are migraine prone we’re seeing that there’s a big change in how their migraines are presenting so that they’re not just headache.
So functionally how does the vestibular system work? Well I like to simplify and it really has 2 major functions, 2 major outputs. The vestibular system through the vestibular ocular reflex or the VOR because I don’t like to say all those words, has a big role, or has the primary role in stabilizing the head or stabilizing vision while your head is moving. That is why I can look out, talk with everybody and still move back and forth and not become dizzy and lose my balance and lose my place. It’s because that reflex works very efficiently, very quickly, and very automatically to make that function happen. Then the second component is through the operation of the vestibulospinal reflex to help control balance. The vestibular system works in concert with visual and somatosensory systems to help provide input for keeping balance. Now one thing I will say again, I’m biased at this point is that in all the concussion literature if you read it, this is what the vestibular system is identified as. And unfortunately as we look at our slow to recover patients, this is not the picture, it’s this is the picture. And so you’ll hear most of my talk is related to the vestibular ocular system.
So if you’re looking, if you’re doing an examination with the patient and you’re not sure if potentially the vestibular system might be involved these are good ways, or good words, or good things to find out about to help to determine if perhaps there’s a problem here. Is your patient complaining of dizziness, are they having balance, especially in darkened environments because in the dark you have to use your vestibular system more because you don’t have your visual system. So getting up in the middle of the night to use the restroom and finding that you need to use the walls more things like that patients will say. They may complain that their vision is blurry or that they have difficulty focusing. Now that could be because of the vestibular issue, it could be because of an ocular motor issue again but it just helps you to probe further. Motion discomfort, heightened motion discomfort, even height phobias. I’ll have patients that tell me that you know I feel very uncomfortable coming down the stairs now, I really need to use the railing or touch the wall and I never had to do that before, telling you all about those issues. And certainly this is a big one, difficulty in busy visual environments, so these are the kids that maybe have trouble in the school hallways or have trouble in the stairwells at school or can’t go to the mall, or the grocery store question. So these are the big things that are out there.
So how do you or what are the common things that we see clinically presenting that are involving the vestibular system. Well one of the largest things is this issue with the vestibular ocular reflex. It’s VOR impairments and again that’s the thing that helps stabilize your head while or stabilize your vision while your head is moving. Dr. Collins showed some nice video yesterday of a very quick visual or quick clinical exam for the VOR and if you’re on the front lines this is something you should be doing to identify whether there’s a problem. Have a person focus on something whether it’s their thumb, I usually use a playing card, something that identifies a target and have them move their head side to side and have them move their head up and down and determine whether they’re having dizziness or whether the image is becoming blurred, those things are going to help you lead very quickly into the fact that there is a VOR issue or there’s not. If there is a VOR issue then vestibular therapists can be very helpful because then we do more detail testing to figure out is this VOR issue coming from central or peripheral causes. We might do a head impulse test, we might do clinical dynamic visual acuity testing, we might do computerized testing that helps us identify the extent of the issue and perhaps where it’s coming from as well. We can also send them for laboratory testing as well, VNGs in addition. But the key here is just identifying it at the beginning phases so that we can begin to address it and then to treat it which I’ll talk about in a minute.
Another vestibular system issue that we’ll see commonly and Dr. Anderson did a great job of kind of eluding to this is this issue of space and motion discomfort and I’ll try to do it justice and describe it. It was, it’s actually been around for quite awhile. We started to identify it early in the 90’s and this wasn’t just typical vestibular patients, patients that were coming in complaining of dizziness, not concussed individuals but they would have trouble in these very busy visual environments. They just felt that they had this heightened awareness, you know they were just extra sensitive to visual and somatosensory motion. There was this hypersensitivity of the system. There are some other terms, some sister terms out there, visual vertigo is one, chronic subjective dizziness, so if you are into the literature those are also things that are probably in the same family. But this phenomena is something that we’re seeing after concussion actually quite a bit. So when we interview patients we’re asking them these key questions. Are you bothered by walking in the supermarket or mall, or whatever a Target or a Walmart or something that is appropriate for that patient trying to identify is there that sensitivity to this visual motion. Are they having trouble in high places? You know again coming down the stairs, or do you have increased sensitivity to heights or wide open spaces, spaces where your visual system is actually challenged a little bit more, things that are new and different. And Dr. Collins shows - and you can play that video - a screen that will do sometimes where you just have a patient follow a moving target which will help to identify whether there’s sensitivity to the system. Now as a therapist I’m looking at their ability to cancel their VOR, I’m doing some other things but actually just even finding out if this elicit a lot of symptoms would be very helpful in identifying does the patient have this visual motion hypersensitivity because you’re looking at their ability to kind of look at the interaction between the visual and the vestibular system. Another way might be to have somebody just be in a busy place. So if you look at this just horrible pattern, how many of you feel uncomfortable looking at this? A little bit. How many of you are getting actually anxious and feel like you need to leave the room and are starting to get a headache and nauseated and dizzy? Okay so if I have a person who has this phenomena, this space and motion discomfort, I literally could put this up for 5 seconds and I would see a response in their face. It will immediately create a constellation of symptoms, it will elicit the problem, so busy patterns are actually a part of our world. Now the interesting thing about this space motion discomfort concept is that it doesn’t exist usually in isolation, it’s not it’s own circle, it’s usually existing with our post traumatic migraine patients because usually it’s the vestibular migraine presentation in addition to the headache migraine as well as an anxiety component too. There’s an overlay and we don’t know what’s, where the chicken and the egg come with this sometimes. We’re not sure but they definitely all fuel each other. So one of the things we do and Dr. Anderson talked a lot about this is that we really use a very combined approach. We’ve got to usually medicate, but we also have to do a lot of vestibular therapy and sometimes behavioral therapy as well and it does, there’s good evidence that that approach works. However, when you have somebody that has this pattern, this presentation it will absolutely take longer to get them better. We’re talking months to get better, not days.
I’ll talk briefly about balance and postural control impairments and the biggest thing that we see is a vestibular system following concussion in this family is impaired sensory organization. And that’s the ability of the balance system to use the different sensory inputs and put them together to balance and maintain so just a fact to remember what the 3 systems are that work in concert to keep you balance, it’s your eyes, your feet, and your inner ear, and those 3 things should be able to work in concert together and they should be able to be more and less active depending on the environmental demands, that should happen automatically without thought. It happens in concussion that this processing is often disrupted especially early on. So what we’ll see is that patients have difficulty using either just vestibular information or only visual information. So there is 3 good ways to test this system. Computerized dynamic posturography if you have 150 grand to have that it’s a wonderful tool and I’m lucky to have it in one of my clinics but not in all, but it is fabulous. It’s considered the gold standard and it was developed Lou Nashner did just amazing work in figuring this out. But it systematically varies the surface, the visual surround so that you can tease out whether there’s a problem organizing the information from the 3 systems. There are 2 clinical versions that are out there to look at the same concept, the same construct. One is the clinical test to sensory interaction for balance or we call it the CTSIB which was a test developed by Ann Shumway-Cook and Faye Horak back in the 80’s. Again works very nicely. The test that’s out there for concussion again looking at the same idea, is the BESS test and probably most of you are familiar with that if you treat concussion. And it’s meant to be a little bit harder of a version of the sensory organization tests, looking at harder conditions, all are eyes closed postures, feet together, single leg stance, tandem stance, both on a solid surface and then on a piece of foam with eyes closed looking at the ability to maintain. The difficult thing about the BESS test I think all of for those of you that use it know is that it’s hard to know without baseline information what’s normal, and there is a lot of variability in it. But it’s an attempt to look at our higher functioning athletes. The issue with balance dysfunction in concussion though is that it absolutely has a lot of value in detecting concussion. There’s value added, there are people who will have impairments in balance who maybe don’t have much more subtle issues in the other system, so it does help identify concussion. However, in recovery from concussion, it’s probably one of the things that improves the quickest in most people, so if you’re using that as your standard for recovery you’ve missed the boat because there’s many more things that are probably going to be slower to recover.
So this is my world, is rehab an option for these things we just talked about? We did a retrospective chart review looking at 144 concussed patients referred for balance vestibular therapy, and found that there was significant changes in all of these different measures of balance of vestibular function, certainly not a randomized control trial. But there isn’t a lot of literature out there. I believe there’s a poster that helps to kind of also go along with what we just said here. So as a therapist I’m interested in and I think a picture is worth a thousand words so I’ll show you some ideas of things that we might do in therapy. People will always ask so what exactly do you do, how do you do vestibular therapy. So I’ll show you some pictures, there just examples. Understand that vestibular therapy is very individualized, we usually meet with patients about once a week, sometimes once or twice a week, sometimes less than that if we have a patient that’s out of town, but it’s home based therapy. We’re giving them things that they’ll be able to do and progress on their own because it’s the repetition, it’s the way to create change in the system. So if you could play the top right video. So if I have somebody that comes in and has a problem with the VOR, the VOR problem, then what I might do is I might actually you know what can you switch and do the top left, I said the wrong thing. That would be a little bit more of an advanced exercise, so they’re having issues. Yeah, sorry, I think I put them in the wrong spot. Okay so this might be where I start, and I’m sorry I’m talking at the beginning just giving him the instructions because actually again home based exercises you really want to make sure they get the concept. But the ideas is I’m giving him a visual target, a plain target to look at on the wall, I’m having him focus on it, move his head at a slow to medium speed keeping that target in focus, and monitoring his dizziness. He’s only doing ten repetitions because at this stage he’s very symptomatic, he gets headaches very easily, he’s very nauseated at times, so that’s where I’m beginning. I might have him do 2 or 3 sets of 10 vertical and horizontal twice a day. That might be it for VOR exercises. However, now go ahead to the bottom one to the third one, so let’s say you’ve got a patient now that’s progressing along. They’ve seen Dr. Anderson, gotten their medications, can you move to the bottom video, that’s it, gotten their medications, they’ve been back to concussion clinic a few times, they’ve really progressed so this might be, and they’ve actually started doing some light exertion therapy as well. So now they’re able to do that gaze stability activity where it’s more functional and actually what we notice is that the vertical gaze stability correlates pretty nicely with being able to run and jog so this is a pretty functional task.
Now what about the patients that have that visual motion, the space motion discomfort that visual motion hypersensitivity issue, what might we do for them? Well we actually try to do grade exposure therapy. We try to do visual motion sensitivity training with them, but I have to tell you, you have to do it very, very carefully because you can definitely set off migraines very easily, very readily in this population so you have to do it in a very structured, very specific way with a lot of instruction. So what we do is we grade our exposure to our certain stimuli that are provocative in a way that is buildable, that you can begin at a certain point and then you can build beyond that. So if you could place the top left, I’ll use my left and right correctly this time.
So this might be a progression. Okay, so this just I might start with something that’s a very busy background and just have him do some visual scanning or some activities where maybe I’ll have them do a little bit of the head turning or maybe I’ll just have them find targets on a busy background, something like that that starts to challenge their visual system a little bit. Again these are examples, there is a million different things. Now if you could switch maybe to the bottom one, so a progression might be a much more difficult progression if you can imagine, so now if you can imagine that the type of optokinetic challenge that’s being provided here. I have him in – if any of you came to the Center for Sports Medicine the other night for the open house this is the balcony area so they are at an overlook. It’s in a busy gym that has a lot of things going on, I’m having him do a lot of backward motion so there is a huge amount of visual flow that he has to process as he’s doing it and he has to track and catch. So that becomes a progression.
And then with these folks we are often using technology. This is a picture of one of our colleagues, Dr. Sue Whitney, her lab at the Eye and Ear Institute here in University of Pittsburgh. It’s a virtual reality cave. This is a – the patient is on a treadmill, they are harnessed and this is like a grocery cart that they are pushing, quote unquote, and this is a grocery store so they are kind of you know the, the screen projects a grocery store so they have to, quote unquote, walk through the grocery store and you can manipulate how complicated the aisles are, you can tell them they are going shopping for catsup and whatever and they have to scan and find it. And it’s a great tool. Unfortunately not everybody can have a virtual reality cave in their home, so what do we do? Well we do the next best thing, and if you play this one for me the top right one, that would be great.
We’ve actually taken to using You Tube a lot so what we do is we, we’ve trolled You Tube to find appropriate types of videos where we can have people immerse themselves in situations that are slightly provocative. So this is just a walking video, try it. If it won’t work I’ll explain. But anyhow it’s you know I don’t know what people do, they go out and they take pictures of everything but we can use it. So walking through busy city streets, so this particular video, there you go, so we are walking through Paris, which is nice but if you have a person who has a lot of these visual motion issues this is extremely discomforting. But what I can do is at any moment we can stop, take a break, let the symptoms go down and then start again. If you can imagine sometimes if I wanted to try to have a patient do this and sent them to the mall well by the time they got to the mall and got there and they became so anxious it would be counterproductive. So this enables us to be able to dose things appropriately and it’s very doable and repeatable which is wonderful.
All right, and then go ahead and show the very bottom one. And then we use – Dr. Collins laughs at me about this one, we do use a disco ball. So again it’s great, they are cheap, you can get them you know kids love them, but the idea here is you know if I have an athlete that’s got to be in a arena or has to be in a football stadium or on a basketball court they sure as heck better be able to process a lot of movement going on around them in lots of different ways. And you know I have them do their reads or do other activities in those environments or do some of their other vestibular exercises and it really helps. Now again you have to be very, very careful about how you dose these, when you introduce them. But just to give you an idea about what types of things we might be doing in vestibular therapy.
We also of course address the balance system. We do it in my therapy, we also do it in my colleague Cara Troutman’s therapy where she’ll be speaking next. But we are looking at manipulating the surfaces, the visual environment, trying to create more demands, we try to ramp that up. Dr. Anderson talked about BPPV too, I would be remiss as a vestibular therapist if I didn’t mention BPPV, so when you have a problem that creates otoconia dislodging in the inner ear we actually treat that mechanically with canalis repositioning maneuvers. Again it would be one of the peripheral reasons why you might be dizziness after a concussion and sports concussion because we are dealing with younger patients and BPPV is a condition that increases in incidence with age so it’s highly correlated to age, we don’t see it as much in the younger population, we do see it occasionally. But if you work with a population of you know motor vehicle accidents, work related injuries, older athletes you will see this more often and it needs to be at least evaluated and looked at by plenty of people.
I won’t go into a lot of cervicogenic issues but clearly as therapists we have to be mindful of the cervicogenic component not only on dizziness but on headaches and on the system in general and all of the things that go into that. And even people who have cervicogenic issues only can have balance and visual problems, oculomotor issues. As vestibular therapists we delve slightly into oculomotor retraining as well, some of the simple things I feel very comfortable addressing, convergence, you know minor convergence issues. We’ll try to treat, if it doesn’t get better we’re sending them to Dr. Steinhoffel who will speak later and his vision therapist, but we’ll do some specific things. We’ll do little things like pencil pushups if you’ll play that top left video, so just looking at a target, bringing it in, trying to keep it one as you bring it in, hold it and then take it out. There are other, there are plenty of other convergence type training but we’ll incorporate that because it’s part of our screen and we’ll add it in. Sometimes it’s enough, sometimes we need to do more. And then we’ll also do things that might help to train, pursuits and saccades if those are issues.
This is just a list if anybody questions about the efficacy. I think that we try to be evidence based in what we do as clinicians and there is some good study about rehab and vestibular rehab, some good information out there about the value. And for those of you that aren’t vestibular therapists if you would choose to try to partner with somebody in your area this is a resource in how to find a vestibular therapist in your area. There is not an accreditation at this point through the American Physical Therapy Association but there is a special interest group, so that’s how to get to that website. However know that vestibular therapists may also still need to be versed in how concussion management, so it’s not exactly the same. Therapist that know how to treat just BPPV are not sufficient, you want somebody that really is, knows how to treat central vestibular problems when you are managing concussion. So another way if nobody is identified on this list might be to look, to speak with your local balance clinics or your local ENT or otoneurology clinics or neurotology clinics and find out who they work with, that might be a good references. And that’s it. So thanks.