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APPROACH TO
RETURN TO PLAYARVIND BALAJI, MD, FAAP
NO FINANCIAL DISCLOSURES
OBJECTIVES
‣ REVIEW CATEGORIES OF NEUROLOGICAL FUNCTION
MOST COMMONLY AFFECTED BY CONCUSSION
‣ NAVIGATE A SYSTEMS-BASED APPROACH TO
RETURN TO PLAY AFTER CONCUSSION
‣ BRIEFLY REVIEW STRATEGIES/PITFALLS OF
CONCUSSION REHABILITATION
CASE
15 y/o M soccer player collides with another player, head-
to-shoulder, during a scrimmage and falls to the ground. He
is slow to get up and is noted to be “wobbly” coming off the
field. The ATC at the game notes that he is slow to respond
to questions so he is restricted from returning to the game.
He is held out of practice for one week and prior to the next
scrimmage, he reports that he is “all better.”
“CAN I PLAY?”
I DON’T KNOW…YET
DIAGNOSIS
SHAKING INJURY TO THE BRAIN
- IMAGING NORMAL
- FUNCTION ABNORMAL
- SYMPTOMS ONSET WITHIN 24HR OF INJURY
Leddy J, Baker JG, Haider MN, Hinds A, Willer B. A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. J Athl Train. 2017;52(3):299-308. doi:10.4085/1062-6050-51.11.08
“SLOWED DOWN”
HEADACHES
DIZZINESS
NAUSEA
FATIGUE
LIGHTHEADEDNESS
DOMAINS AFFECTED
Exercise
Tolerance
Visual/
Vestibular
Mood
Cognition
ALL DOMAINS
MUST BE
ADDRESSED AND
REHABILITATED
EXERCISE TOLERANCE
EXPERIMENTAL HUMAN STUDIES SHOW THAT CONCUSSION
AFFECTS ANS CONTROL OF VENTILATION, PACO2 LEVELS, AND CBF.
ELEVATED PACO2 LEVELS AND CBF DURING EXERCISE ARE
ASSOCIATED WITH SYMPTOMS THAT REDUCE EXERCISE
TOLERANCE IN CONCUSSED PATIENTS.
Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249/JSR.0000000000000505
ANS DYSFUNCTION
CEREBRAL BLOOD FLOW ABNORMALITIES
BREATHING, HR REGULATION, CO2 MANAGEMENT
Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249/JSR.0000000000000505
IS IT SAFE…?
RISK
FORCED EARLY AND HIGH EXERTION WORSENS RECOVERY
Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43(3):265-274. doi:10.4085/1062-6050-43.3.265
BUT…
THE FIRST RCT TO SHOW THAT INDIVIDUALIZED SUBSYMPTOM
THRESHOLD AEROBIC EXERCISE TREATMENT PRESCRIBED TO
ADOLESCENTS WITH CONCUSSION SYMPTOMS DURING THE FIRST
WEEK AFTER SRC SPEEDS RECOVERY AND MAY REDUCE THE
INCIDENCE OF DELAYED RECOVERY.
Leddy JJ, Haider MN, Ellis MJ, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019;173(4):319–325. doi:10.1001/jamapediatrics.2018.4397
MANAGEMENT
ACUTE PHASE: FIRST 24-48 HOURS (V 4TH
CONSENSUS STATEMENT)
EARLY EXERCISE >>> ABSOLUTE REST
- SUB SYMPTOM THRESHOLD EXERTION IN A GRADED
FORMAT (ARP)
ACTIVE REHAB 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
RTP PROTOCOL
1) LIGHT EXERCISE- WALKING OR BIKING
2) MODERATE SPORT SPECIFIC ACTIVITY
3) VIGOROUS NON-CONTACT EXERCISE/RESISTANCE
TRAINING
4) PRACTICE W/ BODY CONTACT
5) RETURN TO PLAY
PROGRESSION BASED ON SYMPTOMS
ARP RISKS
MINIMAL TO NONE, ESPECIALLY WHEN MONITORED
MAIN RISK: EXACERBATING SYMPTOMS
“PUSHING THROUGH” CAN PROLONG RECOVERY
THE CORRECT “DOSE”
GRADUATED ACTIVE REHAB
PROTOCOL BASED ON SYMPTOM
EXACERBATION
VISUAL/VESTIBULAR
100 ADOLESCENTS
MEAN AGE OF 14.5 YEARS
69% HAD ONE OR MORE OF THE FOLLOWING VISION DIAGNOSES:
ACCOMMODATIVE DISORDERS (51%), CONVERGENCE
INSUFFICIENCY (49%), AND SACCADIC DYSFUNCTION (29%).
IN ALL, 46% OF PATIENTS HAD MORE THAN ONE VISION DIAGNOSIS.
Master CL, Scheiman M, Gallaway M, et al. Vision Diagnoses Are Common After Concussion in Adolescents. Clin Pediatr (Phila). 2016;55(3):260-267. doi:10.1177/0009922815594367
INVERSE RELATIONSHIP BETWEEN VOMS
AND EXERCISE TOLERANCE
MORE SYMPTOMATIC WITH VOMS= LOWER TOLERANCE
NPC > 15CM = LOWER TOLERANCE
SCHOOL
EYE-TRACKING ABNORMALITIES WILL
AFFECT STUDENTS’ ABILITIES TO READ
AND TAKE NOTES
SCHOOL PERFORMANCE AFFECTED
TREATMENT…?
REHAB
REHAB
MORE REHAB
COGNITION
Brown, N., Mannix, R., O'Brien, M., Gostine, D., Collins, M. and Meehan, W., 2014. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. PEDIATRICS, 133(2), pp.e299-e304.
TAKE-HOME MESSAGE
THERE ARE SAFE LEVELS OF
COGNITIVE ACTIVITY THAT THE
CONCUSSED PATIENT CAN TOLERATE
WITHOUT RISK OF PROLONGING
SYMPTOMS
PROTECTING STUDENTS DURING
RECOVERY
COMPUTER-BASED TESTS
RETURN TO LEARN
BEFORE RETURN
TO PLAY
MOOD
STUDENTS SUFFERING A CONCUSSION ARE
AT INCREASED RISK FOR POOR MENTAL
OUTCOMES
MULTIFACTORIAL (SCHOOL, ACTIVITY LEVEL,
ETC.)
INJURY ITSELF
Yang MN, Clements-Nolle K, Parrish B, Yang W. Adolescent Concussion and Mental Health Outcomes: A Population-based Study. Am J Health Behav. 2019;43(2):258-265. doi:10.5993/AJHB.43.2.3
PRO-INFLAMMATORY CYTOKINE LEVELS MAY
PERSISTENTLY REMAIN ELEVATED IN THE TIME
FRAME THAT POST-TBI DEPRESSION SYMPTOMS
MAY PERSIST
Yang MN, Clements-Nolle K, Parrish B, Yang W. Adolescent Concussion and Mental Health Outcomes: A Population-based Study. Am J Health Behav. 2019;43(2):258-265. doi:10.5993/AJHB.43.2.3
RISK FACTORS
FOOTBALL HAS THE HIGHEST RATE AMONG HIGH
SCHOOL ATHLETICS
PROLONGED RECOVERY- YOUNGER ATHLETES, PRIOR
CONCUSSION (ESP. IF PROLONGED RECOVERY),
FEMALE SEX, CONCOMITANT MOOD DISORDER
CLEARANCE?STEP 5 ARP/RTP PROTOCOL
BACK TO THE CLASSROOM
NORMAL VISUAL/VESTIBULAR EXAM
SYMPTOM FREE (INCLUDING MOOD, OR BEING ADDRESSED)
COMPLEX RTP DECISIONS
LONG-TERM IMPLICATIONS?
HOW MANY IS TOO MANY?
3-4?
PROLONGED SYMPTOMS?
NEW BASELINE/PERSISTENT DEFICITS?
LOWER IMPACT AND LONGER RECOVERY
LITERATURE IS NOT
CLEAR,
MULTI-DISCIPLINARY
DECISION
SPECIAL THANKS
DR. MO, SPARCC
DR. GRADY, CHOP
QUESTIONS?

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Approach to rtp

  • 1. APPROACH TO RETURN TO PLAYARVIND BALAJI, MD, FAAP
  • 3. OBJECTIVES ‣ REVIEW CATEGORIES OF NEUROLOGICAL FUNCTION MOST COMMONLY AFFECTED BY CONCUSSION ‣ NAVIGATE A SYSTEMS-BASED APPROACH TO RETURN TO PLAY AFTER CONCUSSION ‣ BRIEFLY REVIEW STRATEGIES/PITFALLS OF CONCUSSION REHABILITATION
  • 4. CASE 15 y/o M soccer player collides with another player, head- to-shoulder, during a scrimmage and falls to the ground. He is slow to get up and is noted to be “wobbly” coming off the field. The ATC at the game notes that he is slow to respond to questions so he is restricted from returning to the game. He is held out of practice for one week and prior to the next scrimmage, he reports that he is “all better.”
  • 7. DIAGNOSIS SHAKING INJURY TO THE BRAIN - IMAGING NORMAL - FUNCTION ABNORMAL - SYMPTOMS ONSET WITHIN 24HR OF INJURY Leddy J, Baker JG, Haider MN, Hinds A, Willer B. A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. J Athl Train. 2017;52(3):299-308. doi:10.4085/1062-6050-51.11.08 “SLOWED DOWN” HEADACHES DIZZINESS NAUSEA FATIGUE LIGHTHEADEDNESS
  • 10. EXPERIMENTAL HUMAN STUDIES SHOW THAT CONCUSSION AFFECTS ANS CONTROL OF VENTILATION, PACO2 LEVELS, AND CBF. ELEVATED PACO2 LEVELS AND CBF DURING EXERCISE ARE ASSOCIATED WITH SYMPTOMS THAT REDUCE EXERCISE TOLERANCE IN CONCUSSED PATIENTS. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249/JSR.0000000000000505
  • 11. ANS DYSFUNCTION CEREBRAL BLOOD FLOW ABNORMALITIES BREATHING, HR REGULATION, CO2 MANAGEMENT Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249/JSR.0000000000000505
  • 13. RISK FORCED EARLY AND HIGH EXERTION WORSENS RECOVERY Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43(3):265-274. doi:10.4085/1062-6050-43.3.265
  • 15. THE FIRST RCT TO SHOW THAT INDIVIDUALIZED SUBSYMPTOM THRESHOLD AEROBIC EXERCISE TREATMENT PRESCRIBED TO ADOLESCENTS WITH CONCUSSION SYMPTOMS DURING THE FIRST WEEK AFTER SRC SPEEDS RECOVERY AND MAY REDUCE THE INCIDENCE OF DELAYED RECOVERY. Leddy JJ, Haider MN, Ellis MJ, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019;173(4):319–325. doi:10.1001/jamapediatrics.2018.4397
  • 16.
  • 17. MANAGEMENT ACUTE PHASE: FIRST 24-48 HOURS (V 4TH CONSENSUS STATEMENT) EARLY EXERCISE >>> ABSOLUTE REST - SUB SYMPTOM THRESHOLD EXERTION IN A GRADED FORMAT (ARP)
  • 18. ACTIVE REHAB 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
  • 19. RTP PROTOCOL 1) LIGHT EXERCISE- WALKING OR BIKING 2) MODERATE SPORT SPECIFIC ACTIVITY 3) VIGOROUS NON-CONTACT EXERCISE/RESISTANCE TRAINING 4) PRACTICE W/ BODY CONTACT 5) RETURN TO PLAY PROGRESSION BASED ON SYMPTOMS
  • 20. ARP RISKS MINIMAL TO NONE, ESPECIALLY WHEN MONITORED MAIN RISK: EXACERBATING SYMPTOMS “PUSHING THROUGH” CAN PROLONG RECOVERY
  • 21. THE CORRECT “DOSE” GRADUATED ACTIVE REHAB PROTOCOL BASED ON SYMPTOM EXACERBATION
  • 23. 100 ADOLESCENTS MEAN AGE OF 14.5 YEARS 69% HAD ONE OR MORE OF THE FOLLOWING VISION DIAGNOSES: ACCOMMODATIVE DISORDERS (51%), CONVERGENCE INSUFFICIENCY (49%), AND SACCADIC DYSFUNCTION (29%). IN ALL, 46% OF PATIENTS HAD MORE THAN ONE VISION DIAGNOSIS. Master CL, Scheiman M, Gallaway M, et al. Vision Diagnoses Are Common After Concussion in Adolescents. Clin Pediatr (Phila). 2016;55(3):260-267. doi:10.1177/0009922815594367
  • 24.
  • 25. INVERSE RELATIONSHIP BETWEEN VOMS AND EXERCISE TOLERANCE MORE SYMPTOMATIC WITH VOMS= LOWER TOLERANCE NPC > 15CM = LOWER TOLERANCE
  • 26. SCHOOL EYE-TRACKING ABNORMALITIES WILL AFFECT STUDENTS’ ABILITIES TO READ AND TAKE NOTES SCHOOL PERFORMANCE AFFECTED
  • 29. Brown, N., Mannix, R., O'Brien, M., Gostine, D., Collins, M. and Meehan, W., 2014. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. PEDIATRICS, 133(2), pp.e299-e304.
  • 30. TAKE-HOME MESSAGE THERE ARE SAFE LEVELS OF COGNITIVE ACTIVITY THAT THE CONCUSSED PATIENT CAN TOLERATE WITHOUT RISK OF PROLONGING SYMPTOMS
  • 33. RETURN TO LEARN BEFORE RETURN TO PLAY
  • 34. MOOD
  • 35. STUDENTS SUFFERING A CONCUSSION ARE AT INCREASED RISK FOR POOR MENTAL OUTCOMES MULTIFACTORIAL (SCHOOL, ACTIVITY LEVEL, ETC.) INJURY ITSELF Yang MN, Clements-Nolle K, Parrish B, Yang W. Adolescent Concussion and Mental Health Outcomes: A Population-based Study. Am J Health Behav. 2019;43(2):258-265. doi:10.5993/AJHB.43.2.3
  • 36. PRO-INFLAMMATORY CYTOKINE LEVELS MAY PERSISTENTLY REMAIN ELEVATED IN THE TIME FRAME THAT POST-TBI DEPRESSION SYMPTOMS MAY PERSIST Yang MN, Clements-Nolle K, Parrish B, Yang W. Adolescent Concussion and Mental Health Outcomes: A Population-based Study. Am J Health Behav. 2019;43(2):258-265. doi:10.5993/AJHB.43.2.3
  • 37. RISK FACTORS FOOTBALL HAS THE HIGHEST RATE AMONG HIGH SCHOOL ATHLETICS PROLONGED RECOVERY- YOUNGER ATHLETES, PRIOR CONCUSSION (ESP. IF PROLONGED RECOVERY), FEMALE SEX, CONCOMITANT MOOD DISORDER
  • 38. CLEARANCE?STEP 5 ARP/RTP PROTOCOL BACK TO THE CLASSROOM NORMAL VISUAL/VESTIBULAR EXAM SYMPTOM FREE (INCLUDING MOOD, OR BEING ADDRESSED)
  • 39. COMPLEX RTP DECISIONS LONG-TERM IMPLICATIONS? HOW MANY IS TOO MANY? 3-4? PROLONGED SYMPTOMS? NEW BASELINE/PERSISTENT DEFICITS? LOWER IMPACT AND LONGER RECOVERY LITERATURE IS NOT CLEAR, MULTI-DISCIPLINARY DECISION
  • 40. SPECIAL THANKS DR. MO, SPARCC DR. GRADY, CHOP