Mar 9, 2016Momentum Shift
A new way of treating concussions is stopping sports medicine professionals in their tracks. Instead of rest protocols, experts are prescribing active rehabilitation that includes cognitive stimulation and physical exertion.
This article first appeared in the March 2016 issue of Training and Conditioning.
When the University of Pittsburgh Medical Center (UPMC) invited 37 leading authorities on concussion to a conference last October, the greater sports medicine community expected the meeting to spur collaborative discussion and spirited debate. What they didn’t expect was that the assembled group would turn the standard recommendation for concussion treatment upside down. By the end of the conference, the group announced it was discrediting the notion that rest is the best treatment for head injuries.
“On a global basis, every single person who sustains a concussion is told ‘prolonged rest,'” David Okonkwo, MD, PhD, Professor of Neurological Surgery and Clinical Director of the Brain Trauma Research Center at Pitt, said during a panel discussion following the conference. “Now, you have 37 of the best and brightest minds in the field saying, ‘That’s wrong and, in fact, concussions are treatable, and active treatments are superior to [doing] nothing.'”
Leading the charge for this new way of thinking, the UPMC Sports Medicine Concussion Program believes active rehab is the future of concussion treatment. We were the first to name and identify different concussion profiles, and we create individualized recovery plans based on each athlete’s unique needs. So far, the results have been promising.
Rest has been the recommended concussion treatment method for so long because of two theories. The first comes from an understanding of how the brain responds to head trauma.
When the brain shakes inside the skull, it undergoes metabolic shift. This triggers neuronal depolarization, which causes a release of excitatory neurotransmitters, ionic shifts, changes in glucose metabolism, alterations in cerebral blood flow, and impaired axonal function. The overall energy supply to the brain is thus reduced, so it doesn’t get the energy it needs to heal. Any cognitive or physical activity may further tax an already compromised brain, so rest is recommended.
The second theory is that prescribing rest decreases the potential for reinjury. The brain is most vulnerable during the early stages of concussion recovery, and rest keeps athletes out of potentially hazardous situations.
Some research supports a traditional rest-based recovery model, but the full body of evidence is insufficient to support it as an effective concussion treatment method. Published in Pediatrics, a 2015 randomized pilot trial of 99 patients found that those prescribed a longer rest period had worse symptoms at 10 days post-injury. A separate randomized 2002 study published in the Journal of Neurology, Neurosurgery, and Psychiatry found no benefit to longer rest periods among 107 participants.
There are a number of reasons why traditional rest protocols might have a negative effect on concussion recovery. For starters, athletes who are instructed to rest have a lot of down time to think about how they are feeling, resulting in an increased awareness of symptoms and exacerbated overall fatigue. Others may experience the nocebo effect, which occurs when the mere suggestion of negative outcomes leads patients to subjectively experience intensified symptoms.
Furthermore, the old model of “cocoon therapy” (isolation in a dark room) increases behavioral dysregulation and mood changes. Due to the social isolation and inherent child-parent conflicts with this method-such as arguments over the use of technology, playing outside, and so forth-athletes’ moods may decline. Removing them from established routines, like attending school, may also add stress that can prolong or aggravate symptoms.
A growing body of literature suggests active rehabilitation is a more successful model for concussion management. In a 2013 review published in Frontiers in Human Neuroscience, cognitive and physical stimulation were shown to enhance histologic, cognitive, and behavioral recovery from traumatic brain injury. Similarly, another 2013 study from the same journal found that incorporating cognitive, physical, and social activities in concussion rehab was associated with improved outcomes and a sparing of hippocampal atrophy.
However, just because active rehabilitation can be more beneficial doesn’t mean we completely remove rest from the equation. Of course, we don’t recommend athletes get right back on the field after sustaining a head injury. Rest is needed during this acute recovery stage to support metabolic healing and reduce symptom provocation. The key is including it as part of a broader active treatment plan.
At UPMC, our Sports Medicine Concussion Program is overseen by a strong interdisciplinary team, including neuropsychologists, neurosurgeons, primary care sports medicine physicians, physiatrists, physical therapists, athletic trainers, and behavioral neuro-optometrists. Our treatment protocol begins with three evaluations: a clinical interview, computer-based neurocognitive testing, and a vestibular-ocular-motor screen (VOMS).
Once we have gathered the necessary information on an athlete, we determine their clinical profile. We’ve identified six unique concussion profiles based on which parts of the brain are affected: cognitive, vestibular, ocular, anxiety/mood, cervical, and migraine. Understanding the differences between each one allows us to make responsible and appropriate treatment choices.
An athlete often manifests more than one clinical profile, but they are typically not diagnosed until at least seven days post-injury. Identifying primary, secondary, and tertiary profiles helps us decide on the level and type of cognitive or physical activity to prescribe. Here’s a breakdown of the six profiles and their corresponding treatment plans:
Cognitive: Athletes with this profile may experience headaches, cognitive difficulties, and overall fatigue. We put these individuals on a structured behavioral plan to limit further cognitive fatigue. To increase their energy levels during the day, we regulate their sleep schedule, advise against naps, and incorporate physical activity into their routine. In the absence of vestibular symptoms, they will likely be able to tolerate a range of physical activity but should avoid contact sports or other high-risk endeavors.
As they advance in their recovery, these athletes progress through the five-stage return-to-play (RTP) exertion protocol. They may take longer to complete it than peers without cognitive symptoms due to having higher levels of fatigue.
It’s also important to set up academic accommodations for these athletes, such as incorporating breaks throughout the school day or limiting homework. Occasionally, we’ve encountered teachers who become frustrated when a student asks for accommodations in the classroom while remaining physically active outside of school. When this occurs, we have one of our athletic trainers speak with school administrators and explain our methods.
Vestibular: This clinical profile may include symptoms of dizziness, fogginess, nausea, difficulties with balance, and overstimulation in complex environments. Recommended treatment involves vestibular therapy with a trained neuro-vestibular therapist. Typically, these sessions entail head and eye movement exercises to work on visual motion sensitivity and integration of space and motion. They may also include a balance component.
Due to dizziness and balance issues, these athletes may have difficulty integrating physical activity during the early stages of treatment, but it is critical that they move in some capacity. This can include a daily walk, use of a stationary bike, or light strength work with limited horizontal and vertical movements. As vestibular therapy advances, we incorporate dynamic movement into the final stages of treatment.
From an academic standpoint, student-athletes with vestibular sensitivities may have difficulty in complex visual environments, such as a school cafeteria or crowded hallway. It may help to avoid these spaces early on. Taking notes in class may also trigger a vestibular response, so they may benefit from receiving pre-printed notes or having an assigned notetaker. Having extra time on exams and testing in a quiet environment may help reduce symptoms, as well.
Ocular: Athletes presenting with ocular profiles may experience headaches, fatigue, blurred or double vision, eyestrain, and difficulties concentrating. Ocular problems may include trouble with visual tracking or saccades, in addition to abnormal near point of convergence.
Treatment for an athlete with ocular dysfunction typically includes an evaluation with a behavioral neuro-optometrist and subsequent vision therapy. They may also be prescribed glasses with a prism lens to help redirect wayward eyes.
When this clinical profile occurs in isolation, we recommend a more dynamic physical activity regimen, as binocular vision dysfunction-difficulty moving the eyes simultaneously, equally, and accurately-does not usually trigger symptoms when exercising. However, ocular deficits typically coincide with vestibular involvement, which may limit the extent of physical exertion during the early stages of recovery.
Academically, the student-athlete with ocular dysfunction may have significant difficulty reading and/or using the computer. Audio books and oral exams may be needed for more severe cases. Extra time for assignments and tests, as well as reduced computer work, is recommended.
Anxiety/Mood: Mood changes following concussion are common, with some athletes experiencing anxiety and depression. Longer, complex recoveries may leave athletes more susceptible to emotional variability.
Behavioral regulation is critical for these patients, as they often experience dysregulated sleep, appetite, and physical activity. To re-establish a routine, we ask them to adhere to the same bedtime and wake time every day, with no daytime naps. They are instructed to eat five to six small meals per day and drink at least half of their bodyweight in fluid ounces daily.
A structured exercise plan is important, as well. Thirty minutes of physical activity per day is recommended. Depending on vestibular overlap, these athletes should, at the very least, take a daily walk.
Cervical: Some athletes sustain cervical injury in addition to concussion. In these cases, their level of physical activity is often limited during the early stages of recovery. However, we emphasize at least walking daily and unrestricted cognitive/visual activity unless there is overlap with vestibular, ocular, or cognitive subtypes.
Migraine: Symptoms accompanying this profile may include significant headaches, nausea, and sensitivity to light and/or noise. These issues can become heightened with dysregulated sleep, insufficient nutrient intake, dehydration, and stress.
We keep athletes with this profile on a strict behavioral plan, starting with a regular sleep schedule. To ensure proper fueling, we encourage them to eat five to six small meals a day and hydrate adequately. Some form of physical activity is also important, as this can help manage stress. Intractable migraine sufferers may need to consider medication, as well.
Regardless of the clinical profile, we occasionally encounter athletes who experience exacerbated symptoms following physical activity. When this happens, we typically encourage them to push through symptoms until they reach a 5 or 6 out of 10 in intensity. At that point, the athlete is given a break and reassessed to determine if symptoms reduced. If they do, we will restart the activity. If symptoms do not decrease, we will break for the day. Sometimes, athletes are unable to push past certain exercises without symptom exacerbation, so we switch to a different, less provocative activity until they are able to progress back to the original exercise.
Many of the athletes we see in the UPMC Sports Medicine Concussion Program are suffering from acute head trauma. Because their injuries are so fresh, we employ our active approach from the earliest stages of recovery through return to play.
This was the case with Katie, a 13-year-old basketball player, who came to the clinic less than 24 hours after suffering a concussion in a scrimmage. During her clinical interview, she denied any loss of consciousness following the impact but did report minor post-traumatic amnesia and confusion. Her other symptoms included an 8 out of 10 headache, nausea, sensitivity to light and noise, dizziness, fogginess, difficulty initiating sleep, problems concentrating, and irritability. Katie did not have any personal or family history of migraines but did note a personal history of motion sickness.
Neurocognitive testing revealed Katie had below baseline scores in verbal and visual memory. Her VOMS was highly provocative for headache and dizziness, with saccadic eye movements, horizontal and vertical vestibular-ocular reflex (VOR), and visual motion sensitivity (VMS).
Since her injury was so recent, we didn’t recommend much physical activity following Katie’s first visit. Instead, she was given a strict behavioral plan that included a regulated sleep schedule, adequate hydration, frequent small meals, a daily walk, and stress management. We held her out of school for one full day and two half days and provided academic accommodations for when she returned.
Our team reevaluated Katie one week later. She was back at school full time and reported decreased overall symptoms. The intensity of her headaches had dropped to a 5 out of 10, but she was still experiencing sensitivity to light and noise, fogginess, difficulty initiating sleep, problems concentrating, and irritability. Her neurocognitive test scores remained low, and the VOMS was still significant for provocation of dizziness with horizontal and vertical VOR and VMS. Based on this evaluation, we determined Katie’s primary profile was vestibular, with secondary cognitive fatigue and tertiary migraine. She was given vestibular therapy, and we updated her academic accommodations.
Two weeks later, Katie reported further improvements. She had progressed in vestibular therapy, and her physical therapist had integrated light exertional activities into her regimen. Although she still had minor headaches and difficulty concentrating, her neurocognitive test scores were within normal limits, and the VOMS showed only mild dizziness. Therefore, she started working with an athletic trainer on the RTP exertion protocol.
Katie was discharged from vestibular therapy one week later. She had also completed the RTP protocol and exhibited no symptoms. With these results and normal test scores, she was cleared to return to play.
This case illustrates the importance of integrating information from the clinical interview and VOMS to determine the appropriate time to introduce activity. Given Katie’s history of motion sickness and provocative VOMS at her first examination, we were concerned she would be vulnerable to vestibular involvement during post-injury activity. However, she responded well to light physical exertion and was therefore allowed to begin the RTP protocol prior to being asymptomatic. In turn, this helped progress her vestibular therapy and further decrease her overall symptom profile.
LONG TIME COMING
Not all the cases we encounter are acute like Katie’s. Other athletes come to our clinic weeks or months after their head injuries, yet still suffering debilitating symptoms.
Josh, a 19-year-old college hockey player, is a great example. He sustained a concussion during a game when he was checked into the boards. Because his symptoms didn’t improve within a week of injury, the team physician advised him to withdraw from school and return home to rest.
After two months without any cognitive or physical activity and showing no signs of improvement, Josh came to the UPMC Sports Medicine Concussion Program. His clinical interview revealed a history of two previous concussions that had resolved quickly, as well as a family history of lazy eye, which can be a risk factor for ocular dysfunction. Josh reported that he had already undergone a full vestibular evaluation at home and didn’t need further therapy in this area.
His symptoms included daily headaches averaging an eight out of 10 in intensity that worsened with reading or computer work, difficulties concentrating, and significant mood changes. Josh’s neurocognitive testing revealed that his visual memory, processing speed, and reaction time were all below baseline. The VOMS was within normal limits for all measures, except he had significant near point of convergence insufficiency. In addition, his right eye pulled outward rather than continuing to track in toward his nose. Josh did well in our full exertion evaluation.
Based on these results, we determined Josh had an ocular clinical profile. He was referred to a neuro-optometrist for a full ocular-motor evaluation and vision therapy, which included a home computer-based program that would help strengthen his ocular-motor system.
While Josh was working with the neuro-optometrist, we addressed his mood changes. We felt his two months of complete cognitive and physical rest before coming to UPMC were partly responsible, so we encouraged a return to exercise and social engagement. Josh was provided with a home training plan to advance him through the RTP protocol and on to unrestricted noncontact activities. We also suggested he integrate more social activities into his routine, since he had become isolated from friends.
Josh’s next visit occurred two months later, and he reported significant improvements. He was only experiencing one mild headache per week, and his mood-related concerns had resolved. Visual memory, processing speed, and reaction time were all within normal limits, and his near point convergence had improved.
By this point, Josh was in the final stage of the RTP protocol and reported full aerobic activity without difficulty. In addition, he was halfway through his vision therapy and following his home therapy plan.
Five months later, Josh returned symptom free. His neurocognitive testing results and VOMS backed this up, and he had finished his vision therapy. As a result, we cleared him to return to play.
From Katie’s acute treatment to Josh’s long-term rehab, concussion is a heterogeneous injury. By recognizing distinct clinical profiles and understanding how they may overlap, the UPMC Sports Medicine Concussion Program is able to prescribe active treatment plans that are tailored to each individual. Moving towards an active approach may help eliminate confounding factors of concussion and makes recovery as efficient as possible.
To view the list of references for this article, go to Training-Conditioning.com/References.
Athletic trainers in school or clinical settings who want to incorporate active concussion treatment plans can build off the same clinical profiles we use at the University of Pittsburgh Medical Center’s Sports Medicine Concussion Program. The keys to success are being attentive and flexible.
Begin by closely listening to concussed athletes as they describe how they feel and monitor their symptoms. Using a symptom checklist, determine their severity and what clinical profiles the athlete is exhibiting.
For example, if an athlete is experiencing dizziness, nausea, and fogginess, start with low-intensity physical exertion, such as riding a stationary bike in a quiet environment for a short period of time. If the symptoms are more related to difficulty concentrating or feeling sad, the level of activity can be intensified. Remember, even the most symptomatic athletes should at least be incorporating a daily walk.
RELIEF AT LAST
By Lindsey Holbrook
“I’m sorry, there’s nothing we can do. You’ll just have to wait it out.” This has been the unfortunate prognosis for many who have suffered a concussion with symptoms that linger for weeks-or even years.
At Cognitive FX, a concussion treatment center in Provo, Utah, we’ve been working on a new technique to treat these sufferers of post-concussion syndrome. Our approach incorporates a weeklong “brain boot camp,” called EPIC treatment. (EPIC stands for Enhanced Performance In Cognition.) Patients exert themselves both mentally and physically, exercising their brain’s plasticity to correct damaged neural pathways. We also put them through a series of detailed therapies to overcome their deficiencies in cognition, coordinated motor functioning, and visual and vestibular processing. Although schedules vary, patients spend anywhere from three to eight hours a day in the clinic for three to five days during their week of treatment.
The foundation of the EPIC treatment program is Functional Neurocognitive Imaging (fNCI). Adapted from fMRI technology and neuropsychological testing criterion by our partners Mark Allen, PhD, and Alina Fong, PhD, the fNCI records brain activity while patients respond to questions or images that appear on a screen. This allows physicians to hone in on approximately 60 brain regions and assess levels of cognitive functioning.
Before treatment begins at Cognitive FX, patients undergo the fNCI to detect both the severity of their concussion and patterns of activation and dysregulation in their brains. The preliminary scan is crucial, as it helps direct the course of their treatment and allows us to target their specific deficits.
During their EPIC week, patients work one-on-one with cognitive, neurological, occupational, and neuromuscular therapists who address the specific dysfunctional areas identified by the fNCI. We use a neurocognitive training system, Brain HQ, to provide computerized exercises that are tailored to specific cognitive issues brought on by each individual’s injury. These exercises target areas of memory, attention, reaction speed, sensory processing, and more by requiring the patient to employ both precision and accuracy. To focus on difficulties in visual tracking, motor coordination, and balance, we use various tools, including DynaVision and neuromuscular therapy.
After a week of EPIC treatment, patients finish the program with a second fNCI scan to identify areas of improvement and determine whether further action is necessary. Each individual receives a customized exit packet containing guidelines to ensure they are able to maintain the benefits achieved at Cognitive FX. All patients are welcome to return to the clinic for a booster day or specific treatments, if needed.
Since Cognitive FX opened in 2014, we’ve had great success with our methods. In a study comparing the results of treatment versus no treatment, we looked at 56 patients who went through the EPIC program and 19 who did not. Everyone who received treatment showed varying levels of improvement, with a majority demonstrating significant gains. Of the 19 individuals who did not undergo the brain boot camp, most stayed the same or saw their symptoms worsen.
Additionally, our results show little correlation between length of time since injury and positive response to treatment. The vast majority of patients seen at Cognitive FX come within 24 months of their injury. However, we’ve also achieved positive results with patients who experienced concussion as many as 15 to 50 years prior to treatment.
The protocols and processes implemented at Cognitive FX are scientifically based and backed by research found in tier-1, peer-reviewed journals. A breadth of treatment outcome research is currently underway at our facility, along with longevity improvement rates. These results will be published in 2016.
Lindsey Holbrook works closely with patients and partners as the Lead Psychometrist at Cognitive FX in Provo, Utah, and is part of both the therapy and research teams. More information is at: www.cognitivefxusa.com.