Disclaimer: This PowerPoint is a brief summary of

1. 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.

2. Mild TBI & Concussion Assessment & Treatment

3. Dr. Barry WillerUniversity at Buffalo, Concussion ClinicNHLBuffalo Sabres FoundationOntario HockeyHockey CanadaSalt Lake City Winter Olympics • http://www.youtube.com/watch?v=xXl6LPIoXUg

4. Definitions: 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 weeks 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

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

6. How will our clients present? • Headaches • Photophobia • Poor sleep • Dizziness

7. 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.

8. Quick Refresher Sympathetic Nervous System • ↑ HR • Pupils dilate • Inhibits digestion • Inhibits nasal secretions • Inhibits saliva production • Inhibits liver/kidneys/gall bladder • Stimulates sweating • Causes piloerection • Makes lungs dilate • ↑ muscle strength Parasympathetic Nervous System • ↓ HR • Pupils contract • Stimulates digestion • Causes nasal secretions • Stimulates liver/kidneys/gall bladder • Causes constriction inside the lungs i.e. “fight or flight” vs “rest and digest”

9. Sympathetic Overdrive • Imbalance between our sympathetic and parasympathetic nervous systems • Parasympathetic system does not “kick in” • Poor sleep hygiene • Light sensitivity

10. 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

11. Cerebrovascular & Cardiovascular Benefits of Exercise

12. 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.

13. 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

15. 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 treatment significantly 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

16. 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 TreatmentJohn 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

17. Questions?