Return to Exercise and Sport

Mo Mortazavi, MD

Mo Mortazavi, MD SPARCC Sports Medicine, Rehabilitation, and Concussion Center Pediatrics, Tucson Medical Center Medical Director, TUSD Inter Scholastics

No financial disclosures Outline

 Return to exercise after concussion  The “Active Rehab Protocol”  Managing Exercise Intolerance  Return to Play/Sport Protocol  Complex RTP Decisions Case

 14 year old quarterback  Sacked in the backfield, severe headache  Does not tell ATC/Coach  Mentions it to mom that night  Has problems concentrating in school  Returns to play 2 days after event Case

 Returns to play  Minor blow to back, head snaps back  NO LOC  Appears stunned, tries to play  Starts walking off field after a minute  Collapses to ground, semi-comatose  Dilating pupils, respiratory failure, DEATH  Remember: SECOND IMPACT SYNDROME! Second Impact Syndrome

 What is Second Impact Syndrome?  Second-impact syndrome refers to the catastrophic events which may occur when a second concussion occurs while the athlete is still symptomatic and healing from a previous concussion.  Risk of “Second Impact Syndrome”  Can cause rapid swelling around the brain often resulting in severe neurological damage or death!

AZ Concussion Bill: SB 1521 Requirements

1) Risk awareness and education 2) Removal from play 3) Parental Notification 4) Medical clearance REQ! Case

 11 y/o girl head to floor 2 weeks ago  Told ok to RTP in 1-2 weeks  Remains slightly symptomatic  Exam normal (but VOMS +)  Dying to practice/scrimmage  Lack of exercise make her moody

Management: 5th Consensus

 Research supports multi-disciplinary therapeutic approach:  Return to Learn and cognitive support  Return to play protocol  Vestibulocular rehabilitation  Cervical rehabilitation  Graded Exertional Rehabilitation (ARP)

5th Consensus (Rehab Updates)

 Acute Phase Considered first 24-48hrs (as opposed to 2-3 weeks -4th Consensus)  Early Intervention > Absolute Rest  Sub symptom threshold exertional rehab protocol (Revised RTP)  Vestibulocular/cervical exercises  Implement Return to Learn

“limiting the duration of rest in the first days after an injury is one of the most important messages of the guideline.”

-Co-author Matthew J. Breiding, CDC, Atlanta, Georgia

Emerging data suggest that symptom-limited activity, including activities of daily living and non- contact aerobic exercise, may begin as soon as tolerated after an initial brief period (24–48hours) of cognitive and physical relative rest.

CJSM 2019 Active Rehab Protocol (ARP)

 Begin at 24-48hrs ONLY if tolerated  Sub symptom threshold exertion  Monitored exertional tolerance test  Establish SAFE exertional step:  Intensity  Modality  Duration

Active Rehab Protocol (ARP)

 Multiple Protocols (Buffalo Protocol)  BCTT (treadmill), BCBT (bike)  Determine exertional “dose”  5 Step Protocol:  Step 1-Light (50-60% MHR)  Step 2- Moderate (60-70% MHR)  Step 3- Vigorous (70-80% MHR)  Step 4- Maximal (80-90% MHR)  Step 5- Maximal with MDM (bridge sport)

5 Step Protocol (Mode Progression) ARP: Risks/Side Effects

 Studies to date have shown little to no adverse risks  Main risk is exacerbation of symptoms:  Pushing through the threshold  Eager athletes may not endorse Sx  Not following strict protocol/parameters  Highly symptomatic or VOMS + patient may not be ready (Syncope/Fall risk)  Exertional Dysautonomia Exercise Intolerance?

 Symptoms during exercise:  HA, dizziness, pre-syncope, nausea  Fatigue, SOB, “out of shape”  Causes:  Vestibular dysfunction  Visual dysfunction  Autonomic Dysfunction  Deconditioning  Psychogenic/Burnout VOMS and Exercise Tolerance

 Inverse relationship  Pan Positive VOMS = poor tolerance  NPC>16cm = Poor tolerance (step 1 or 2)

CJSM 2019 Exertional Dysautonomia

 Autonomic dysfunction can lead to exercise intolerance (CBF instability)  HR/BP response to exercise  Rate of rise, HRV, decline with cool down  BP control during exercise  Orthostatic (tilt test) BP/HR instability  Pupillary reflex speeds  Others: Sweating dysfunction, heat homeostasis, cortisol insufficiency, glucose metab, GI dysfunction

Management of Dysautonomia

 Sub-threshold exertion (Levine protocol)  Autonomic rehab (Mayo Clinic):  Biofeeback  Cardio respiratory exercises  Positional dysautonomia (POTS):  Postural and LE resistance exercises  Hydration and Salt  Medications (propanolol, florinef)

Case

 16 y/o with ball to face last week  Brief LOC, HA, dizziness, concentration  Reports full resolution 5 days later  Normal exam  Wants to play in tomorrows game Cleared?

 ALL symptoms resolved?  School workload? Concentration?  Does asymptomatic = Recovered?  Did exam include VOMS? Exertional challenge?  Graded Exertional RTP protocol per 5th Consensus? Sports Clearance

 Must meet several requirements:  Must be symptom free (off meds)  Normal exam (includes VOMS)  Back to full time/workload at school  Cognitive testing back to BL/norms  Maximal exercise tolerance (RTP protocol) Return to Play Protocol (RTP)

1. Light exercise: Walking or stationary cycling 2. Moderate sport specific activity with lateral movement 3. Vigorous non contact exertion, resistance training Medical Clearance recheck required 4. Practice with body contact and no symptoms 5. Return to game play

Note: If symptoms worsen/return, resume protocol in 24hrs at the previous step.

5th Consensus Statement on Concussion in Sport. BJSM April 2017.

Additional Points

 Must be symptom-free off meds  OK to continue ADHD & antidepressant medications Neurocognitive Testing

 Degree/type of cognitive impairment  Baseline vs normative data  Sport clearance tool:  20-30% of “Asymptomatic” athletes continue to show cognitive deficits  Added 3-10d to RTP timeline in HS athletes

Collins etal 2011 Broglio etal 2007 ImPACT ®Clinical Report EMILY DERICKSON

Exam T ype Base line Post-Injury 1 Dat e T es t ed 08/19/2014 10/30/2014 Las t Concus s ion Exam Language English English T es t Vers ion 2.1 2.1

Compos it e S cores Percent ile s cores if available are lis t ed in s mall t ype.

Me m ory com posite (ve rbal) 82 31% 63 <1% Me m ory com posite (visual) 45 1% 53 5% Visual m otor spe e d com posite 29 9% 31.28 15% Re action tim e com posite 0.52 83% 0.57 58% Im pulse control com posite 19 17 T ot al S ympt om S core 4 69 Cognit ive Ef f iciency Index * 0.32 0.15

The Cognitive Efficiency Index meas ures the interaction between accuracy (percentage correct) and s peed (reaction time) in s econds on the Symbol Match tes t. This s core was not developed to make return to play decis ions but can be helpful in determining the extent to which the athlete tried to work very fas t on s ymbol match (decreas ing accuracy) or attempted to improve their accuracy by taking a more deliberate and s low approach (jeopardiz ing s peed). Low s cores (0 to .20 ) may in s ome cas es s ugges t a very poor performance on this s ubtes t.

Scores in bold RED type exceed the Reliable Change Index (RCI) when compared to the bas eline s core. However, s cores that do not exceed to RCI index may s till be clinically s ignificant. Percentile s cores if available are lis ted in s mall type.

Hours s lept las t night 6 Medicat ion singulair

ImPACT is not intended to provide a diagnos is or decis ion about the Tes t Taker. ImPACT res ults s hould be interpreted only by qualified healthcare profes s ionals .

Page 2 07/21/2017 Complex RTP decisions

 Concerns for long term complications?  How many is too many?  What do we know?  Limited high level data (hard to study)  BU CTE autopsies (Case series)  More Cog >3 (Retrospective data)  More questions than answers  Certainly there are concerns Contact/Collision (Retirement)

 “Grey Area” where discussion begins:  3-4 lifetime mTBIs (no magic number)  >6-12 months symptoms after mTBI  Lower impacts, Longer recovery times  Athlete apprehension  Persistent symptoms/deficits:  Cognitive/visual  Mood/personality  Autonomic  Exercise intolerance

Sports at High Risk for Concussions

 Football  Ice Hockey  Wrestling  Basketball  Soccer  Lacrosse/Field Hockey  Cheer (flyer/base)  Gymnastics  Diving  Water polo  Mountain biking  Baseball  Volleyball

The 3 “Ps”

 Consider the “3 Ps”  Prior history (of multiple concussions)  Prolonged (recovery from injuries)  Proximity (of head injuries)

 The Concussion, The Patient, Their World...  Patient history (concussions, co-morbidities)  Type of sport(s)  Value/Benefit of the sport(s)  Alternatives

William Osler Additional aides

 Can utilize more sophisticated visual or cognitive tests on case by case basis  All very sensitive tools:  NP testing  Auditory evoked potentials (qEEG)  Oculomotor tracker, vision testing  MRI with DTI/functional scans

My Conversation...

 No evidence based guidelines  Expert opinion  Literature review  Risk and benefit review (if risk deemed reasonable)  Never risk free  Written Informed Consent

Reminders for Days Following Concussion

 All need RTP protocol  Early Intervention centered around the active rehab protocol (ARP)  Managing Exercise Intolerance  Be conservative with return to contact or high risk sport  Complex RTP discussions Prevention?

 Helmets?  Guardian Caps?  Header bands?  Sensors?

Do Helmets Protect Against Concussions?

 Research has NOT shown a decrease in rates of concussion with newer helmets  Decrease in skull fractures Concussion Prevention

 Properly fitted equipment  Rules/laws:  Limit forceful collisions  Senate bill 1521  Appropriate recognition and diagnosis (Education)  Age appropriate sporting rules  Cervical and visual spatial training Baseline Testing

 NO UNIVERSAL RECOMMENDATIONS  Control for variability of normative data  Cognitive testing most commonly done  Balance, vision, reaction time other domains with comprehensive BL tests  Most critical in high risk athletes