Disclaimer: This PowerPoint is a brief summary of PRELIMINARY RESEARCH. It is intended for educational

purposes and not meant to be adopted as treatment protocol.

Mild TBI & ConcussionAssessment & Treatment

Dr. Barry WillerUniversity at Buffalo, Concussion Clinic

NHLBuffalo Sabres Foundation

Ontario HockeyHockey Canada

Salt Lake City Winter Olympics

http://www.youtube.com/watch?v=xXl6LPIoXUg

Definitions:o Concussion:- short-term alternation of

consciousness due to a trauma- caused by movement of the brain

inside the skull- involves metabolic changes- usually recovery within 2 weekso Post Concussion Syndrome/Mild TBI- symptoms persist beyond 2 weeks- physiologic characteristics include:

- ↑ HR - ↑ BP (diastolic during exercise)- ↑ HR variability

(parasympathetic response)- ↑ cerebral blood flow during

exercise

Physiology metabolic chain reaction of brain neurochemical changes after

concussion that produces an initial hypermetabolic state followed by a state of metabolic depression

may explain why: some symptoms are delayed in onset or worsen over time

some patients report symptom resolution before they demonstrate physical and cognitive homeostasis

patients who are asymptomatic at rest can become symptomatic during physical or cognitive exertion

Regulatory and Autoregulatory Physiological Dysfunction as a Primary Characteristic of Post Concussion Syndrome: Implications for Treatment

John J. Leddy, Karl Kozlowski, Michael Fung, David R. Pendergast, and Barry Willer, NeuroRehabilitation 2007

How will our clients present?

Headaches Photophobia Poor sleep Dizziness

Post Concussion Syndrome (PCS) 5-10% of ppl who experience

concussions will have symptoms that persist beyond 6 weeks.

There is no known cause for persistent symptoms after a concussion.

A prior history of concussions will increase the likelihood of PCS.

The most common symptom is headache.

Experiencing dizziness is the most definitive predictor of poor outcomes long-term.

“Rest is best” theory (no exercise)

Prescription of anti-depressants is the most common treatment.

Quick RefresherSympathetic Nervous SystemSympathetic Nervous System↑ ↑ HRHRPupils dilatePupils dilateInhibits digestionInhibits digestionInhibits nasal secretionsInhibits nasal secretionsInhibits saliva productionInhibits saliva productionInhibits liver/kidneys/gall bladderInhibits liver/kidneys/gall bladderStimulates sweatingStimulates sweatingCauses piloerectionCauses piloerectionMakes lungs dilateMakes lungs dilate↑ ↑ muscle strengthmuscle strength

Parasympathetic Nervous SystemParasympathetic Nervous System↓ ↓ HRHRPupils contractPupils contractStimulates digestionStimulates digestionCauses nasal secretionsCauses nasal secretionsStimulates liver/kidneys/gall bladderStimulates liver/kidneys/gall bladderCauses constriction inside the lungsCauses constriction inside the lungs

i.e. “fight or flight” i.e. “fight or flight” vsvs

““rest and digest”rest and digest”

Sympathetic Overdrive

Imbalance between our sympathetic and parasympathetic nervous systems

Parasympathetic system does not “kick in” Poor sleep hygiene Light sensitivity

Exercise to Address PCS Rationale:

the regulatory system responsible for maintaining cerebral blood flow, which may be dysfunctional in people with a concussion, can be restored to normal by controlled, graded symptom-free exercise.

Subsymptom Threshold Exercise Training (SSTET) Dr. Willer advises only

aerobic exercise for the treatment of PCS.

http://www.medicalnewstoday.com/releases/53995.php

Cerebrovascular & Cardiovascular Benefits of

Exercise

PCS vs Cervical Strain

If a client is able to exercise to the point of exhaustion and their headache IMPROVES, they may have cervical strain. ↑ endorphins ↑ blood flow Muscles relax

A heat pack on their neck should reduce their headache.

Note: Cervical strain may cause dizziness due to the fact that our neck has both pain sensors and vestibular sensors.

So What?

Treadmill Test Speed = 3.4 mph Incline = 0% HR monitor Borg RPE Scale Record of symptom onset

Ability to exercise to point of voluntary exhaustion w/out symptom exacerbation = “physiologically recovered”

Clients respond well to “seeing” improvement

Study Results: Symptom Reduction

FIGURE 1. Athlete versus nonathlete improvement in mean number of daily symptoms (with 95% confidence intervals) by weeks of exercise treatment. Athletes completed treatmentsignificantly faster than nonathletes.A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post-Concussion SyndromeJohn J. Leddy, Karl Kozlowski, James P. Donnelly, David R. Pendergast, Leonard H. Epstein, and Barry Willer Clin J Sport Med Volume 20, Number 1, January 2010

References http://www.medicalnewstoday.com/releases/53995.php http://

journals.lww.com/cjsportsmed/Fulltext/2011/03000/Reliability_of_a_Graded_Exercise_Test_for.3.aspx

Regulatory and Autoregulatory Physiological Dysfunction as a Primary Characteristic of Post Concussion Syndrome: Implications for Treatment

John J. Leddy, Karl Kozlowski, Michael Fung, David R. Pendergast, and Barry Willer, NeuroRehabilitation 2007

A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post-Concussion SyndromeJohn J. Leddy, Karl Kozlowski, James P. Donnelly, David R. Pendergast, Leonard H. Epstein, and Barry WillerClin J Sport Med Volume 20, Number 1, January 2010

http://medicine.buffalo.edu/faculty/profile.html?ubit=bswiller http://concussion.buffalo.edu/ bswiller@buffalo.edu

Questions?