RETURN TO SPORT AFTER CONCUSSION

Neil Pathare, MDBoard Certified, Orthopaedic Surgery

FAAOS

Sports Medicine

Disclosures

• None

Concussion Neurometabolic Cascade

• Risks to premature return to play during period of vulnerability include: – A greater risk for a second concussion due to a lower concussion threshold. – Second impact syndrome (abnormal brain blood flow that can result in death). – Exacerbation of any current symptoms. – Increased risk of injury due to alteration in balance.

Return to Play Timeframe• The time frame for RTS may vary with player age, history, and level of sport. Management

must be individualized. (McCrory et al. 2013; Karlin 2011)

• Athletes who have suffered a prior injury have up to a 5.8 fold increased rate of re‐injury (Schulz 2014).

– RTP guidelines may need to be adjusted for those who have experienced a prior head

injury.

– A Hx of multiple concussions involves emphasizing the need to consider the long‐term

consequences and recovery prior to RTP. (Harmon et al. 2012)

Return to Play: When is it safe?

• Clinical Recovery– Cognitive recovery

– Postural Stability (Balance)

– Vestibular‐Ocular Motor recovery

- Smooth Pursuits

- Saccadic or Rapid Eye Movements

– Symptom free without medications

– Tolerance of physical exertion

– Neuropsychological assessment

- ImPACT testing

• Barlow et al. Pediatrics. 2010

– Adults: 10‐14 days

– Children + Adolescents: Up to 4 weeks

- 10‐45% of children will have persistent

symptoms for >3months

- 2% will have symptoms for >1 year

NOTE: There are no standardized measures to define clinical recovery from concussion

Physiologic Recovery

• Functional MRI (fMRI)• Diffusion tensor imaging (DTI)• Magnetic resonance spectroscopy (MRS)• Cerebral blood flow (CBF)• Fluid biomarkers• Transcranial magnetic stimulation (TMS)

NOTE: These tools remain experimental at this time. (McCrory et al., Br J Sports Med. 2017)

Return to Activity

• When it is safe

– 1st Return to Learn

– Then Return to Sport- Stepwise rehab strategy

Return to Play Treatment Algorithm

www.cattonline.com

How much rest is best?• “...the best available evidence from

clinical studies does not support the efficacy of prescribing complete rest for more than a few days following SRC. “ (Schneider et al., 2017)

• “...too much activity can hinder recovery, but strict rest can do the same.” (McLeod et al., 2017)

• “Physical exercise appears to improve PCSS scores & symptoms in patients with concussion.” (Lal et al., 2017)– Increased levels of brain‐derived neurotrophic

factor (BDNF)– Improved spatial memory– Cortical connectivity and activation

How much rest is best?

• Could too much rest actually be bad?

– Mood dysregulation (Wells et al., 2015)

– Being sedentary following injury or illness is one of the most consistent risk factors for

chronic disability (Silverberg & Iverson, 2013)

– Depression (DiFazio et al., 2015)

– Anxiety/Nocebo Effect (DiFazio et al., 2015)

– Physical deconditioning (Silverberg & Iverson, 2013; DiFazio et al., 2015)

Return to Play Treatment Algorithm

www.cattonline.com

Standardized assessment/Controlled Exercise

• Buffalo Concussion Treadmill Test (BCTT) (Leddy et al., Curr Sports Med Rep. 2013.)

– Gradually increasing exercise intensity

– Serial measurements of HR, BP, and RPE (Rate of perceived exertion)

– Allows for individualized management protocols

– Safe Return to Play, through re‐established exercise tolerance (Leddy et al., 2011)

• Treadmill with 15% incline

• Heart rate monitor

• Exercise clothes and shoes

• Water, towel, and a chair

Equipment and Preparation

Borg’s Rating of Perceived Exertion (RPE) Scale

How hard you feel like your body is working

Visual Analog Scale (VAS)

How good/bad your symptoms are making you feel right now

Data Collection

BCTT Protocol Speed is set for Brisk walking Inclination is progressively increased

1 degree/min Once 15 degrees is reach, speed is

increased by 0.4mph/min Participant rates RPE and symptom

severity every minute Subjective scores and HR are

recorded

Stopping Criteria

Maximum exertion (RPE score of ≥17-19) is reported

Significant increase in pain or symptom severity

Rapid progression of complaints (ex. Headache, patient appears faint or unsteady

Patient or clinician report an inability to continue the test safely

(Leddy JJ, Baker J, Willer B., 2016)

Exercise prescription Exercise Rx based on 80% of the maximum heart rate reached without symptoms

20-30 min/day of aerobic exercise at 80% max HR Swimming, walking or stationary cycling No resistance training

Heart rate may be 5‐10 bpm weekly as tolerated

Continue until 85‐90% of APMHR (age predicted maximal heart rate) for 20 mins without symptoms, then repeat BCTT.

Exercise Rx If the patient can exercise to voluntary exhaustion on the BCTT without symptoms, may

begin return to play algorithm

Other prescriptions and recommendations will be based on the patient’s particular complaints. Cervical physical therapy, vestibular physical therapy, or treatment for

temporomandibular joint disorders

• Current guidelines do not account for the variability within different Sports – Physicians, coaches, and athletic trainers face challenges in making sure each athlete is able to withstand

the rigors of their specific sport.

Sports Specific Return to Play

Sports Specific Return to Play

• Cheerleading, Gymnastics, Football, Wrestling, Soccer, Basketball, Lacrosse, Baseball/Softball, Ice Hockey

Return to Play Treatment Algorithm

www.cattonline.com

Knowledge Translation

• Education and Awareness– Athletes, Parents, Coaches, Athletic Trainers, Physicians, Health Care

Providers, etc.

• Your health is most important• If you are injured you are not going to perform your best• You are not going to be the best contribution for your team• You will take longer to heal• It’s easier to re‐injure yourself

When in doubt, Keep them out!

Thank you

References• McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on Concussion in Sport‐The 4th International

Conference on Concussion in Sport held in Zurich, November 2012. J Sci Med Sport 2013;16:178‐89• Karlin AM. Concussion in the pediatric and adolescent population: “Different population, different concerns”.

Pm&R. 2011;3:S369‐79• Schulz MR, Marshall SW, Mueller FO, et al. Incidence and risk factors for concussion in high school athletes, North

Carolina, 1996‐1999. Am J Epidemiol 2004;160:937‐44• Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement:

concussion in sport. Br J Sports Med. 2012;47:15‐26 • Schneider KJ, Leddy JJ, Guskiewicz KM, Seifert T, McCrea M, Silverberg ND, Feddermann‐Demont N, Iverson GL,

Hayden A, Makdissi M. Rest and treatment/rehabilitation following sport‐related concussion: a systematic review. Br J Sports Med. 2017 Jun;51(12):930‐934.

• May KH, Marshall DL, Burns TG, Popoli DM, Polikandriotis JA. Pediatric sports specific return to play guidelines following concussion. Int J Sports Phys Ther. 2014 Apr;9(2):242‐55.

• Giza C, Greco T, Prins ML. Concussion: pathophysiology and clinical translation. Handb Clin Neurol. 2018;158:51‐61.

• Leddy JJ, Hinds AL, Miecznikowski J, Darling S, Matuszak J, Baker JG, Picano J, Willer B. Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: A Randomized Trial. Clin J Sport Med. 2018 Jan;28(1):13‐20.

• Lal A, Kolakowsky‐Hayner SA, Ghajar J, Balamane M. The Effect of Physical Exercise After a Concussion: A Systematic Review and Meta‐analysis. Am J Sports Med. 2018 Mar;46(3):743‐752.