Darby Swain and Lauren Small present "Team Up: Multidisciplinary approach to Concussion Rehabilitation" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
I'll start with introducing Darby Swain. Uh, she is a sports physical therapist here at our Sports medicine Center for young athletes. Uh, she received her BS in exercise physiology at Cal State Chico and her doctorate of physical therapy um there as well. I'm not sure Samuel, sorry about that. And she's been here with us at U CS F for almost two years now and is a significant part of our concussion management team within the department. She'll be joined by Lauren Small who is the head athletic trainer at Berkeley High School and she's been so for the past 11 years and is also the coordinator of our concussion program here at U CS F. Um, she received her BS in kinesiology with an emphasis in athletic training, uh at San Jose State and a Masters in Sports Health from A T still university. She's heavily involved in the coordination of care for a lot of our local Bay Area athletes. She also does a lot of education for coaches and primary care providers and is really a huge asset to our primary care sports or pediatric sports team here at U CS F. So we welcome you both uh to close us off. Hi, everybody. Um I'm Darby, I'm Lauren and we are here to talk about team up the multidisciplinary approach to concussion rehab and return to play. We do not have any financial disclosures related to content in this presentation and here are our objectives. So to start us off, um we wanted to again define what a concussion is according to that fifth international consensus in sport in Berlin 2016, it is composed of either a direct or indirect blow anywhere on the body head or face that causes forces to be transmitted to the head. You have an immediate or delayed impairment of neurological function typically with um negative imaging. So it's more of a functional versus a structural injury and you can or cannot have an episode of loss of consciousness. Again, we just heard that this um definition is continuing to be updated. So it'll be interesting to see what the new one is. Um coming out at the end of this year. Why should we care about concussions specifically within our population that we're primarily working with? Um There are about 283,000 Children, 18 and younger that are treated in emergency departments for sports related concussions every year. Between the years of 2001 and 2013, 3.24 million concussions were treated in the emergency department in primary care facilities on athletic training fields. Um And on average 2.5 million high school students reported at least one sports related concussion a year and more than one million reported more than one. Um and again, these numbers are likely really gross underestimations as many athletes that sustain sports related concussions are not properly diagnosed or don't seek medical treatment. And these numbers just show that we really truly do, um see a lot of these concussions within our clinics and again in athletic training rooms and that it's really important that we understand how to treat um and care for these athletes. When we see them, when we look at concussion rates per 10,000 athlete exposures. Um Pierpoint and Collins looked between the oh five oh six and 2013 2014 seasons and showed just kind of some general trends um with specific sports. So in general, football and hockey had the highest reported um concussion exposure and an athlete exposure is one athlete participating in one practice or competition. But then when we look again, um at sports that have both male and female athletes, we see the trend being higher in women than men. Um when it comes to patients suffering from concussions. Ok. A and uh like doctor, we was uh discussing earlier, there is a multitude of um ways in which concussions can present themselves. It also can change over time. They may not present initially with specific symptoms that may come on later that day or even the next day. But then also having things like um vestibular symptoms can then affect their cognitive, can then affect it all can affect each other and it can make things harder to diagnose but also more challenging to treat as well. No, no, don't do that one. Uh Oh OK. Um So with the multidisciplinary approach, there are pretty much just three teams that are involved in that um uh care. First one is the family team which would include parents, guardians, siblings, friends, teammates, all those people that um the athlete is or patient is used to seeing on a regular basis and are a very large part of their lives. Then there is the school team which would include the athletic trainer, coaches, teachers, counselors, administrators, and then the medical team, which would be primary care physician, um primary care provider, physiotherapist concussion specialist, if that's what's needed, depending upon the severity and the length of the and then athletic trainer and then uh possibly an optometrist if needed. Um parent athlete education doctor. We talked about this a little bit so we're not going to go into it. Super detailed. Um, physical rest is important, but only for a couple days and then it can actually become an issue if they are spending too much time in doing cocoon therapy and all they're doing is thinking about how they feel and how they're missing out on all these things. So there is a balance that needs to be made between um, the rest and staying home and not doing anything. And then also the, um, getting back to some semblance of life, um, which essentially is doing things that don't make your symptoms worse, um, but still being involved. So a lot of times in the clinic will be like, well, you know, they start doing things like helping with the dishes or, you know, doing some stuff around the house that they're not just sitting in their room sleeping the whole time. Um, and, um, figuring out kind of what does and does not affect them is important as well as the early, um, sub symptomatic, uh, exercise as well is also important. Um, and essentially the, the goal is, is to make it help parents and athletes understand, unlike other injuries that sometimes they'll kind of push through and that sort of stuff with this type of an injury, it's really important to stay subst level while you're recovering. So, pushing through while it isn't going to make any long term lasting effects, it may make the concussion last longer. I always tell them it's kind of like poking a bruise even though that's not what a concussion is. It at least gives an idea. If you keep touching a bruise over and over and over again, it takes longer to heal, it takes longer for it to get better. And that's one of the ways I kind of explain. Well, whenever you're doing things that cause symptoms you're kind of continuing to like poke that bruise. Um, they have to return to learn before they return to play. This is key. Uh We require that they have to be completely caught up in school before we talk about any sort of return to um, contact or game play. And, um should, um, if that is not, if rest and gradual return activities is, is not, um, you know, doesn't seem to be going well after about a week or two, then that's when it's looking at referring to potentially to a sports medicine or neurologist um to get some more um specialized help and then potentially also seeing um if physical therapy would be appropriate as well and really important because there's a lot of anxiety behind concussions that they will recover um with the multiple, if they're not recovering just with the basic stuff, it may require multidisciplinary approach, but they will recover and that's essential to understand what is an athletic trainer. I just threw this in here. Um I because national athletic training month. So um um we are highly qualified multi skilled health care professionals who run a service or treatment under the direction of or in collaboration with the physician in accordance with their, with our education training state statutes, rules and regulations. And we provide um services including primary care injury, illness prevention, wellness, promotion and education, emergent care, examination, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions. So we're kind of like Jack of all trades. Um And we're generally speaking, we're, we're, our traditional setting is in more of the school type setting, but we are found in a lot of teams and then also um uh clinics, um, some physical therapy clinics have them. Um I do outreach where I'm in the orthopedic department, but I'm also at the, at a high school. So it's kind of a combination. Um our role is unique because we are on the campus or site of practices and games on a regular basis. Um which often means that we are the ones that are getting to know the athletes and seeing them whenever they need something. Um, there's no need to make an appointment, there's no need for, you know, having to deal with insurance and, you know, have only so many visits a year and deductibles and all that sort of stuff. We don't have any of that. So, um, we're kind of like a drop in clinic to begin with and then we can really do a lot with coordinating between all the members of the care of the care team. So me being on campus means that I can work with the athletic directors, I can work with the counselors, I can work with teachers, I can work with parents guardians, all of it to help coordinate the care for that athlete patient, whatever, you know, either way. Um, not just for concussions, but for anything, but specifically with concussions, it makes things a lot easier for the athlete when they have somebody that they can go to with questions whenever they need to and don't have to wait until the next time they see their primary care physician or their physical therapist or whoever. Um, and after an injury, we're most likely the first or second contact. Um, we are able to recognize, assess and refer for a possible concussion to a primary care provider in the state. Any time that an athlete under the age of 18 is, um, sustains an injury that may be a concussion. They must see a, um, a MD D O provider that has is training in, in um concussion man diagnosis and concussion management and they have to receive written clearance before they can return to play. If they are diagnosed, then there has to be a minimum of seven days from the date of diagnosis and they have to follow the, the full return to play protocol. So there's multi steps behind it in order to help make sure that the athletes aren't returning too soon. And then after that, a lot of times I'll have athletes that have come to gone to the primary care doctor. They come back to me, they have, they hand me a note that's kind of like pretty basic as far as what um the information is in it. But then by talking to them, I can kind of ascertain what is more specific things that need to need to happen. Um and also monitor if I notice any red flags. If I notice there's, they're really struggling with mental health or in a specific class, they're really struggling with a specific teacher, those sort of things, that's where I can kind of help intervene earlier so that it hopefully doesn't get to a place where it becomes a more stressful situation for the athlete patient. And then I'm also able to supervise home exercise program, return to play protocols and com just communicate with everybody um school wise. Um because a lot of times we know that you primary care physicians don't have time to sit down and write down a whole accommodations thing. And Dr Wade did put on there, the C I F uh accommodations form. That's great. If you and I highly recommend recommend that you print those off and have those available. If not, then if your patient has an athletic trainer, they may also be able to do the same sort of thing of saying, ok. So light's really bothering you. Here's some things that we can ask from your teachers. Ok. So you're really having a hard time reading. Here's some, here's some ways that we can possibly um modify things. So you're still participating, you're not falling behind, but you're also not exacerbating those symptoms. Um And then same thing with cognitive, yeah, your memory's not the greatest right now. We probably shouldn't be having you taking tests because you're not gonna probably do very well. And then we're looking at you having to either retake them or having bad grades. We don't want that either. Um, so that's kind of the goals of the athletic training role within the school is to just kind of really help with guiding the athlete, athlete and parents from that standpoint. Great. Um, so now I'm gonna talk about P T rehab principles. So when these athletes or patients come into our clinic, what are the things that we need to look at? Assess and then how do we translate that into treatment? Um A really timely article was just published in the international Journal of Sports Physical Therapy in February of this year that looked at basically the effectiveness of physical therapy interventions in athletes post concussion. It was a systematic review that looked at eight different studies and basically came to the conclusion that interventions such as aerobic and multimodal approach rehab showed significant improvements in time to recovery and reduction in post concussion symptoms and activity in rehab. As early as a couple of days, days following injury can be beneficial. So after we have that initial 24 to 48 hours of rest, really starting to initiate some of these rehab principles. Um is an important thing because we see better recovery and to return to sport versus traditional physical and cognitive rest. So when we think about how we're going to assess and treat these individuals. Um The physical therapy um journal of orthopedic sports, physical therapy published AC P G in 2020 that divided it into four primary domains, the visual vestibular autonomic and aerobic and cervical. And we're gonna dive kind of into each of these four areas. Next, they also started the C P G by outlining. Well, how do we sequence our exam with these individuals? Um We start with our subjective exam first, triaging for neck pain, irritability and then for dizziness and headaches. And if they are reporting cervical symptoms, we need to exam here first and then proceed with the visual vestibular and autonomic assessment. So, with cervical rehab, um Schneider at all, published a study that looked at patients who suffered sports related concussions. Um The group that received some sort of cervical rehab along with other forms of treatment versus groups that did not have these cervical interventions. And they showed that these individuals were about four times more likely to return to participation in eight weeks or less versus patients that did not receive cervical rehab and concussion and cervicogenic symptoms present really similarly. So it's important to use proper tests and measures to help tease out. Well, which of these symptoms are coming from the neck and which are coming from these other three domains. So this chart um was adapted from that same article and it breaks down the different clinical tests that we can use for these patients within the um cervical realm, looking for symptoms such as dizziness, vertigo, pain, visual disturbances, and then treatment options for each of these different assessments. So if we start at the bottom kind of the low hanging fruit is our cervical range of motion, palpation of suboccipital upper traps, uh paraspinals, elevator and then throughout the entire cervical region. Treatment for those types of dysfunctions typically centers around manual therapy and then we progress into our motor control assessment. Um looking at deep cervical flexor and extensor training along with more manual therapy. And then the four kind of above that are more special tests that we can look at to really tease out um different aspects of the cervical spine. Looking at the cervical flexion rotation tests for more upper cervical spine dysfunction and then head neck differentiation testing, smooth pursuit, neck torsion tests and cervical joint reposition error as well. Moving along to visual and vestibular rehab, visual and vestibular dysfunction occurs in approximately 60% of athletes after a concussion. So being able to understand how to assess and treat in this domain is um an important part of the rehab process. The upper three boxes are looking at the visual examination and then the bottom three or more vestibular. So for visual, we need to be looking um at smooth pursuits, C codes and convergence for smooth pursuits. And so we're gonna look in three directions, the horizontal, the vertical and the diagonal and we're looking at this in terms of beats per minute. So typically with the Metronome App starting anywhere 80 to 90 looking for increase in their symptoms, looking for changes in their visual processing with the goal of eventually getting them to 100 and 20 beats per minute. Um For convergence, we're looking for less than six centimeters and then for V R V R cancellation, same idea again, all three directions with the goal of 100 and 20. The best test which was on this previous slide is one of the best um or the most highly researched tests and most validated test for individuals with concussions. It's three different positions. So feet together, single leg stance and tandem stances, eyes closed on flat surface and on foam, you are counting errors which can be opening the eyes, taking hands off hip, um falling off the balance pad. Um and then you're tallying the points up basically for each of the domains. They have a maximum of 10 points for each section. And then you're looking for our age group anywhere from 8 to 14 errors is what's shown in the research as kind of normal. Um And then again, just kind of looking to see a decrease in those numbers as we progress. And then finally, the dicks Hallpike if this is indicated, um It's definitely something that we should examine and then go ahead and treat, but not all patients with concussions will um need this kind of treatment. So it's definitely really teasing this out in your subjective exam. So now that we understand how to um examine in the visual and vestibular domain, um it's important to understand how we prescribe exercise, how we dose it and then how we progress and regress it. So there was a great article published um changes in V O R um and ocular motor screen scores in adolescence, treated with vestibular therapy after concussion that goes into dosage for home exercise programs. So it was 77 patients with concussions versus 77 without they received vestibular physical therapy one time a week um during a clinical visit and then their H E P that started approximately 20 days after their concussion. They wanted these individuals to perform the H E P three times a day with each exercise varying from 1 to 2 minutes and they were looking at the intensity. So they didn't want the dizziness to be provoked by more than three points. And if that was the case, then they had to stop the exercise, have it resolved within 60 seconds and then they could go back and try it again. And the results were that all of the V O MS items improve significantly except for near near point convergent distance. So I think this is just a great outline of where we can really start. And the nice thing about all of the tests for the visual and vestibular system is they can turn directly into exercises. So if someone is having issues with, you give them at the beats per minute that they're struggling with and then you can progress by altering one or more of the following things. The base of support that they're standing on or the surface posture, trunk and arm position, visual input, cognitive, dual tasking the speed. Again, the beats per minute and trunk and arm positioning, you can combine these things, you can just tease out one versus the other. Um And then this table is a really good resource if you're looking to um find a place to start. So they go through each of these different um areas that we've examined. They give an example for an exercise and again how to progress and regress them. So looking at smooth pursuit, you give them the smooth pursuit exercise and then as they come back into clinic, you can progress it by increasing the speed of the moving target, alter the surface or their base of support, have them do it with lunges, adding complex visual backgrounds. So again, just a good resource slide for um exercise, ideas, dosage for these exercises. Um this applies to all of these H E P but also to anything that they're struggling with. So return to learn, studying school work, we really wanna establish their symptom threshold very early on. So what are their symptoms that day with the goal of avoiding this Yoyo effect. So anywhere of a 2 to 3 point increase in the literature for baseline is OK. But again, we want that to resolve really quickly after you stop, the exercise, start with your lower sets and reps and then build. And again, this applies to all aspects of rehab and recovery. And then finally, we're gonna look at the autonomic and aerobic rehab. Um Again, this is triggered by a metabolic cascade where the brain is initially in this hypermetabolic state and then transitions to a hypermetabolic state. And the most research tests to dose and prescribe exercise in this domain is the Buffalo Concussion treadmill test. Um Just to review, you will establish baseline symptoms. VA s of 0 to 10. It is a treadmill test. Um You wanna establish their resting heart rate after two minutes and then they start walking on the treadmill at 3.2 miles an hour and gradually increase the incline and then eventually the speed and then you're monitoring their heart rate, um their symptom score and their R pe and then the test will either finish in one of two ways. It's either gonna be voluntary exhaustion. So they, you know, their symptoms are fine but they're like, hey, I need to stop because this is too hard. So 17 or more on the R pe or symptom exacerbation. So if they have three points or more on the visual analog scale with one point for an increase in severity of an existing symptom or one point for an onset of a new symptom, that's where the test stops. And then based on those two different possible endings, that's how we get into our exercise prescription. So if they stop because of voluntary exhaustion, um they're safe to exercise at any heart rate up to the maximum achieved. And we're kind of checking this box off when we're thinking of the different domains. If they stop because of symptom exacerbation, then the heart rate that they stop at is their heart rate threshold. And then we're gonna prescribe them aerobic exercise at um anywhere less than 90% of this heart rate threshold. Typically 80 to 90 is where the literature kind of the general consensus in the literature. And then you can do it for either like the time. So if they got to this heart rate threshold in 10 minutes, then you start them at 10 minutes or based on this research article, exercises, Medicine for concussion, you can start it anywhere from 15 to 20 minutes a day. So they reviewed kind of the current concepts for this aerobic threshold and how to prescribe exercise. And this was their outline that they used. Um So again, another resource for a starting point for this type of exercise prescription, they started at 80 to 90% of that heart rate threshold for 15 to 20 minutes a day. They stopped exercise at the first sign of symptom exacerbation or after 15 to 20 minutes of the target heart rate, they progressed time first and then heart rate by 5 to 10 beats per minute every 1 to 2 weeks. And then this physiological recovery occurred when the patient could exercise to voluntary exhaustion. At 80% of their age predicted max heart rate for 20 minutes, several days in a row without the symptoms. So, again, just a good outline for where we start with this aerobic exercise. I'm gonna turn it back over to war. So, uh so athletic training, uh our role in terms of injury recovery is primarily providing guidance, education regarding activity and home exercise, prescription and being able to communicate with primary care, doctors, specialists, P T visits to um make sure everybody's getting staying coordinated in terms of what um is working and maybe what still needs to be addressed with, with the patient. Uh We can also supplement where appropriate. So for example, if we realize maybe they are having some issues with their vision, giving them some exercises or some B O R exercises to help um with that, if in the event that they either can't get into physical therapy or we're waiting on them getting in or whatever the situation is, we also work with the coaches and school personnel to keep the patients safely involved in school and sports activities like we talked about with uh earlier in the day, their identity is that they're an athlete and they really have a hard time not being able to do what they consider themselves being. So, even though they may not be able to uh play in the basketball game, we still encourage them to go to the game as long as the lights aren't increasing their symptoms if the noise is bothering them to wear ear plugs or ear buds, but to stay involved as much as they can with their team and with their classmates is an essential part of this recovery because it decreases the likelihood of them having um some anxiety, depression symptoms, um just becoming separated and kind of isolated from their normal friend group. Um And then we also just are able to identify if there's any additional areas of support or treatment modifications that may be needed. Um You know, if we're noticing they are having some struggles with mental health, you know, connecting with their counselor at the, at the school or, you know, get letting their parents know, hey, I kind of noticed that, you know, it seems like he's a little more down than he normally is. Um And then also we're able to kind of see often before other health care providers because we can see them every day, twice a day or whatever is um if the recovery is taking longer than it should, despite adherence and kind of be like, you know, I think we kind of need to maybe talk to your doctor do we need to get some vision therapy. Do we need to have you go and see like a, a sports psychologist, what else can we do to kind of help you along in this process? Uh So for both athletic trainers, physical therapists, PC P S, who, whoever, um to a certain extent at schools that don't have athletic trainers, it's gonna be the coach or the athletic director. There's a return to sport guided progression. The idea behind it is the same with return to learn is we want to do a stepwise process. We don't wanna just jump straight in. Um So we don't just want to say, ok, when you feel better, you can go back to practice like you want to have that step by step by step to make sure that we can figure out when is it that they're getting symptoms? But also are they safely able to return? And the return to sport return to play protocol is adapted from the C I F concussion return to play protocol. It is on the same website that doctor we was talking about. We also have, I have the website in writing for you on the la on the second to last slide. Um But that is a requirement is they have to follow a graduate return apply and it has to be I think, I believe it's at least five steps. Um That is an essential part of making sure that they're not returning before they're ready, which then can cause, you know, a higher likelihood of another injury, whether it be a concussion or something else. So, to begin, stage two, which is the non contact progression, they have to be asymptomatic or have physician clearance to begin the protocol. That just means, you know, we have to make sure that they're being monitored and they're educated to begin contact activities. Patient must be fully caught up in school and back to the regular academic load. They must be asymptomatic with all noncontact activities and they have to have written clearance from the provider or physician that um diagnosed them or specialist. Um, this written clearance is something that can sometimes be a little bit of a challenge because they need to get that note from their doctor or whoever like their provider. And a lot of times the kids or parents or provider isn't aware of that prior to the appointment. And so it can sometimes take a little bit longer. So being aware that that is actually a requirement for them to return to play following a concussion is um essential. And for the steps, you can only progress one stage per day if symptoms don't return or worsen. So if they are out of step and they go the next step and they get symptoms, they get worse or symptoms come back, then they need to take a step back. They need to check in with whoever is their concussion. Monitor and then they need to wait a day and then try again, if they can't do it three times, then they need to seek further medical attention. It's the same slide. Um The main thing is just, there is a green line between the non contact and the full, the limited full contact practice and the full contact practice because that is when you need the written clearance. Um according to state law, so that is kind of like that key cut off of you can only go to here. And the, the idea behind the steps is that you start out with just facing forward walking, you're not going up and down with running. So it's biking or walking if they can handle that, that's when you add in. So maybe some running. So there's a little bit more visual um uh issues um potentially can, it's gonna cause more vision issues. If there are those and you're increasing the heart rate, then you're increasing the heart rate even more and then you're adding in like weight lifting. So 50% of their macs, then noncontact training is gonna add in even more of the sport specific movements, their head turning, they're cutting all of those other aspects that can also cause symptom returns. Um So they have to be able to pass all of that in order to be able to get clear, to be, to even do a contact practice. And they have to have at least one contact practice before they can play in a game for football. The idea is to have at least one limited and one full contact practice before their game so that we know that they're not going to have any exacerbation of symptoms in the middle of a game and not want to say anything or any of the other fun stuff that can happen. All right. And then this is the website, it's the same as the, the QR just written out for you and it has all of the forms, the C I F is for high school athletes. However, the forms can be used for all levels of school and youth athletic activity. And the laws do apply to not only high school but also uh, clubs, rec teams, middle schools, any sort of athletic, um, team, um, is required to follow the same rules. So, and that's it.
