Concussion Management – After the Hit

1. Concussion Management – After the Hit Brian Werner, PT, MPT President – Werner Institute for Balance and Dizziness Disorders Rebecca Cheema, ATC, PTA, EdD

2. Dr. Cheema’s Perspective Is Concussion Management Saturated – Do we really know all aspects of a concussion? What I have learned in a Dizziness Clinic over the year? Vestibular System and its effect on brain function and recovery

3. History of Concussion Management Early and Late 1990’s - Computerized Neurocognitive Testing (Headminder, ImPACT) Late 1999’s – BESS vs. Computerized - Balance Performance Testing 2004 – NATA Position Statement 2008 - Zurich Statement on RTP Criteria 2008 – SAC and SAC II 2010 – NCAA 2011 …

4. Zurich Statement – Graduated RTP - 2008 Functional Exercise at Each Stage of Rehabilitation 1. No activity Complete physical and cognitive rest OBJECTIVE: Recovery 2. Light aerobic exercise Walking, swimming or stationary cycling keeping intensity <70% MPHR. No resistance training. OBJECTIVE: Increase HR 3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities. OBJECTIVE: Add movement 4. Non-contact training drills Progression to more complex training drills (e.g. passing drills in football and ice hockey). May start progressive resistance training). OBJECTIVE: Exercise, coordination, cognitive load 5. Full contact practice Following medical clearance, participate in normal training activities OBJECTIVE: Restore confidence, assessment of functional skills by coaching staff 6. Return to play OBJECTIVE: Normal game play

5. History of Concussion Management Early and Late 1990’s - Computerized Neurocognitive Testing (Headminder, ImPACT) Late 1999’s – BESS vs. Computerized - Balance Performance Testing 2004 – NATA Position Statement 2008 - Zurich Statement on RTP Criteria 2008 – SAC and SAC II 2010 – NCAA 2011 …

6. NFL launches new guidelines for assessing concussions BASELINE TEST Concussion History Self Reported Symptoms SAC Modified BESS Where are the vestibular tests? The league will utilize "standardized" sideline procedures for assessing whether players have sustained concussions during a game or practice and whether they have crossed the "No Go" threshold for removal.

7. NFL Sideline

8. Presentation Objectives Cerebral versus Vestibular Concussion – Is there a difference? What is the Vestibular System and How Can It Get Damaged? Why is It So Important to Differentiate Cerebral versus Vestibular Concussion in the Concussed Athlete? Training Room Testing for Vestibular Dysfunction in the Athlete – When and How? Treatment of Vestibular Dysfunction Athlete – How Does It Work?

9. Cerebral versus Vestibular Concussion – Is there a Difference?

10. The Concussion – What We Know… Defined as an immediate acceleration and deceleration or stopping event, resulting in temporary or permanent damage to the “structures” of the head. Lets not get caught up that every concussion is cerebral! This injury is likely associated with low levels of axonal stretch resulting in temporary changes in neurophysiology. (Giza and Hovda, 2004) The vestibular structures are also affected…they are part of the head.

11. Difference Between Cerebral and Vestibular Concussion – Symptom Onset and Resolution Cerebral symptoms come on strong and resolves quickly 7-10 days Vestibular symptoms may also be at onset but can be delayed and progressively worsens with time Days, weeks, to months Avoidance Behaviors The symptoms themselves can be similar in nature - Lance Jackson, MD Neurotologist (EIT), 2011

12. What is the Vestibular System, What Does Do, and How Can It Get Damaged?

13. What is the Vestibular System? Complex set of sensors imbedded in the temporal bone of the skull. Not just your ears… Cranial Nerve system (CN VIII) Brainstem Vestibular Nuclei Parts of the cerebellum This is where symptoms can be mixed…cerebral vs. vestibular Big Question: How Do I know which one is injured – Peripheral, Central or Both …you must know what you are testing.

14. Sensors of the Inner Ear Semicircular Canals Otolith Organs Linear Accelerometers Angular Accelerometers Key – these are accelerometers – abnormal accelerations are the common cause to concussions…

15. What Do They Control • YAW • PITCH • ROLL • BOB • HEAVE • SURGE • EYES, HEAD ON NECK, POSTURE

16. Primary Functions of the Vestibular System (VOR) Maintains gaze stability of the eyes (VCR) Maintains position of head on neck (VSR) Maintains balance during transitions, standing, and gait New thoughts…

17. The Vestibular – Cognition Connection – New Thoughts • Damage to the vestibular system can directly create cognitive deficits • Spatial navigation • Object recognition memory • You don’t have to have symptoms of dizziness to have the cognitive symptoms (Smith et al, 2005, Hanes, 2006 – Journal of Vestibular Research) • Could improvement in vestibular function reduce cognitive dysfunction? • Example: Zach T.

18. The Vestibular-Blood Flow Connection – New Findings out of Harvard • The purpose of the otolith organ of the inner ear is assist in auto-regulation of blood flow to the head. • Injury to this organ can lead to symptoms that commonly are thought to be cerebral deficits. • Serrador,et al, 2008 • Dr. Leddy – Univ. of Buffalo Program

19. The Vestibular-Autonomic Nervous System Connection • Vestibular system lesions produce a number of injurious effects, including: • Disruption in the ability to rapidly adjust blood pressure • Respiratory muscle activity during movement and changes in posture • These perturbations in autonomic regulation are transient, and largely dissipate over time. • Could we be seeing a disruption of the vestibular system as the cause of the symptoms of concussion?

20. What Structures Are Injured to the Vestibular System After Concussion? Actual sensors (otolith/cupula of SCC) or entire end organ gets damaged Baro-trauma, blunt injury, blast/shockwave from hit Traction/tethering of the CNVIII nerve From the origin of the sensor In the axons of the nerve itself From the insertion in the brainstem

21. Why is It So Important to Differentiate Vestibular from Cerebral Concussion?

22. Because We Are Missing Athletes Young kids… Ex. Stuart N. Ex. Zach T. Older athletes/soldiers Bob J. Chelsea O. Symptom management lacking specificity

23. Vestibular Dysfunction Symptoms That Can Mimic Cerebral Concussion Signs (in the clinic) VOR (Gaze Instability) Visual Sensitivity, Headaches, Difficulty concentrating, fatigue, cognitive dysfunction VCR (Cervical Instability) Visual Sensitivity, Headaches, Cervical Pain/Stiffness VSR (Postural Instability) Balance problems, fatigue, cognitive dysfunction Dizziness? What does that identify?

24. What is Dizziness? (Kroenke, 2001)

25. Dizziness is a Non-Specific Term Example – Pain can be described as: Sharp, shooting, burning, aching, deep, superficial, tension, pounding, etc. Where is the injury? Mechanism of Injury? Time frame on healing? More specific vocabulary assists medial professionals in providing the proper care

26. Vestibular System Injury Causes Symptoms That Mimic Cerebral Concussion Example: Vestibular Neuritis (Non-Contact) No injury to the cerebral system yet damage to the inner ear Classic symptoms and secondary symptoms include: Note: You don’t have to feel the primary symptoms to have secondary.

27. Training Room Testing for Vestibular Dysfunction in the Athlete – When and How?

28. Before the Hit… Prior to Concussion Baseline test/Combines NCAA 2010 requires it. Identify at-risk athletes to prevent future injury Identify old injury not known

29. After the Hit… Zurich Stage 1. No activity - Complete physical and cognitive rest OBJECTIVE: Recovery VESTIBULAR TESTING SHOULD BE DONE WITH NEUROCOGNITIVE! Zurich Stage 2. Light aerobic exercise Walking, swimming or stationary cycling keeping intensity <70% MPHR. No resistance training.

30. Training Room Vestibular Tests Gaze Stability Oculomotor Screen (Saccade, Smooth Pursuits) Slow VOR Head Impulse Test (Head Thrust) Illegible-E/Dynamic Visual Acuity Tests Dix-Hallpike Test Postural Stability Singleton FUKUDA Tandem Gait – Eyes Closed BESS Station

31. Your Identification is the Key to Proper Management Identify vestibular component and refer them out if non-resolution after day four… (Zurich, 2008) Physical Therapy and Audiology that specializes in vestibular disorders Medical Doctor with Audiology – Neurotologist - ENT

32. Tests That Measure Vestibular Function Videonystagmography Computerized Dynamic Posturography Rotational Testing Passive Chair Testing Active Rotation Testing Vestibular Evoked Myogenic Potentials InVision DVA and GST Testing

33. Treatment of Athlete with Vestibular Dysfunction - How Does It Work?

34. Vestibular Rehabilitation • Started in the mid to late 1940’s • Cawthorne and Cooksey • Treatment of concussed soldiers • Set of eye, head, and body activities to induce movement to facilitate central compensation

35. Vestibular Rehabilitation 1980’s – Susan Herdman, PT, PhD started to develop custom treatment approaches to the Cawthorne exercises CC Exercises too general and not specific Telian and Shepard, 1985 – Custom Vestibular Rehabilitation 85% resolution or significant reduction in symptoms compared to CC Exercises where on 55% resolution Cochrane Collaboration (2007) Vestibular rehabilitation is effective.

36. Treatment of Vestibular Dysfunction Using BRPT Principle I Dizziness is an error message – avoidance of the symptom actually prolongs disorder. Principle II Use the same treatment techniques you would use to treat an ankle sprain/strain Repetitions and Sets Small movements to dynamic movements Symptoms as your guide

37. Treatment of Vestibular Dysfunction Using BRPT Principle III – Taxonomy of Task Progression for Static/Dynamic Balance Open/Closed Environment No Intertrial/Intertrial Variability Without/With manipulation Body Stable/Body Transport

38. Gaze Stability Exercises Fixed/Moving targets Variable distances from targets Simple to complex visual backgrounds Simple to complex surfaces during: Sitting Standing Gait

39. References Kroenke, K., Lucas, C.A., Rosenberg, M.L., etal. (1992). Causes of persistent dizziness: A prospective study of 100 patients in ambulatory care. Annals of Internal Medicine, 117, 898–904. Cawthorne, T. (1944). The physiological basis for head exercises. J Chart Soc Physiother 106-7. El-Kashlan, HK., et al. (1998). Disability from vestibular symptoms after acoustic neuroma. American Journal of Otology 19:101-114. Hain, T. (2006). http://www.dizziness-and-balance.com/treatment/rehab.html Horak, FB., et al. (1992). Effects of Vestibular rehabilitation on dizziness and imbalance. Otolaryngology – Head and Neck Surgery 106: 175-9. Kreb, DE., et al. (2003). Vestibular Rehabilitation: useful but not universally so. Otolaryngology – Head and Neck Surgery. 128: 240-50. Norre, M. (1988). Vestibular habituation training. Archives of Otolaryngology – Head and Neck Surgery 114: 883-86. Solomon, D & Shepard, N. (2002). Chronic Dizziness. Current Treatment Options in Neurology: Ophthalmology and Otology. 281-288. Whitney, et al. (2000). Efficacy of vestibular rehabilitation. Otolaryngologic Clinics of North America. 33,3; 659-673. Whitney, et al (2003). The effect of age on vestibular rehabilitation outcomes. Laryngoscope. 112,10: 1785-90.