Safe Return to Activity (RTA) - Minnesota Brain Injury Alliance

Report
SAFE RETURN TO ACTIVITY (RTA)
AFTER MILD TRAUMATIC BRAIN
INJURY (MTBI)
OBJECTIVES
•
Review what is a mild Traumatic Brain Injury including
causes and symptoms associated with concussion.
•
Discussion on assessment of concussions and
implications
•
Management of concussions including school
accommodations
•
Role of Physical Therapy to allow your student/athlete
to safely return to play.
New Minnesota Law
CHAPTER 90--S.F.No. 612.
•Effective September 1, 2011
•Minnesota State Law requires coaches and/or officials
• To remove youth athletes from participating in any
youth athletic activity when the youth athlete exhibits
signs, symptoms, or behaviors consistent with a
concussion; or is suspected of sustaining a
concussion.
• In order to return to activity the youth must be
symptom free & evaluated by a provider trained and
experienced in evaluating & managing concussions
• Coaches and officials must complete an online
training every 3 years
•
https://www.revisor.mn.gov/laws/?id=90&year=2011&type=0
HISTORY OF THE
NEUROTRAUMA CLINIC AT
GILLETTE
Gillette Children’s Neurotrauma Clinic
• Began May 2007
• Children between 0-21
years
• Mild to moderate injury
• Patient Seen -over 1700
• Mechanisms of Injury
• Sports
• MVA
• Car vs bike
• Car vs pedestrian
• Falls
• Assault
• Brain Injuries
• Fractures and Bleeds
• Spine Injuries
• Cervical strains
• Fractures
• Compression fracture
• SCIWORA
REVIEW OF MILD TBI’S
Traumatic Brain Injury
“Defined as a complex
pathophysiologic process affecting the
brain, induced by traumatic
biomechanical forces secondary to
direct or indirect forces to the head.”
http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf
Concussion - Definition
• Complex process affecting the brain
• Induced by traumatic forces
• Direct or Indirect
• Functional Disturbance rather than Structural
Injury
• No abnormality on standard structural neuroimaging
• Have seen students/athletes after concussion who have
had an MRI and because it is normal they are told to
return to activity.
Acceleration/Deceleration
Brain moves forward in
skull
Frontal lobes strike
inside of skull
Rebound contre coup
injury to the occipital
lobe
Rotational Injury
-
-
-
Brain rotates on axis causing
stretching/tearing of axon
Stretching and tearing of blood vessels
results in hematoma
Brain strikes skull causing contusion
Causes of TBI
Sports-Related Head
Injuries: 300,000 per
year in U. S.
MVA
Other
Assaults
Sports
Centers for Disease Control and Prevention 2000
Recreation TBI
Deaths: > 500 per
year
Mild Traumatic Brain Injury
-
-
-
Results in a graded set of clinical syndromes
that may or may not involve loss of
consciousness.
Resolution of the clinical and cognitive
symptoms typically follows a sequential
course
Typically associated with grossly normal
neuroimaging studies
Acute clinical symptoms reflect a functional
disturbance rather than structural injury
Mild Traumatic Brain Injury
Mild TBI can cause functional changes,
which are interactive:




Cognition (learning, memory and reasoning)
Sensation
Language (communication, expression, and
understanding)
Emotion (depression, anxiety, personality
changes, aggression, acting out, social
inappropriateness)
500
(Giza & Hovda, 2001)
Calcium
400
% of normal
-
K+
300
Glucose
200
Glutamate
100
50
2
6
0
Cerebral Blood Flow
12
minutes
20
30
6
24
hours
3
6
10
days
UCLA Brain Injury Research Center
Guidelines for Return to Play
•
•
Guidelines for return to play have been created with this
data in mind, avoiding a time period where the brain is
more vulnerable to injury due to the energy crisis of the
brain
Difficult to definitively define the period of vulnerability
following TBI, each injury is different with varied effect on
the cascade
ASSESSMENT OF
MILD TBI
Assessment
•
•
•
Physical exam to rule out bleed, neck
injury, spine injury
Neurocognitive screening/developmental
screening
CT scans and MRIs of the head are
usually normal and are not necessary
unless the patient has increasing
symptoms of concern
Asking about symptoms
Specific yes/no questions about the more subtle
symptoms is more effective than asking open
ended questions.
• “Asymptomatic” is not an easily defined term,
though is at the core of proper concussion
management
•
Symptoms may be delayed or
recurrent
Many athletes may seemingly “normalize”
within minutes of an injury, but then have a
recurrence and potential worsening
minutes to hours later
• IMPLICATION: very rare same-day return
to play
•
Signs and Symptoms
Somatic:
• Headache, pressure, neck pain, n/v, vision changes,
balance problems, light or noise sensitivity, “don’t feel
right”
Cognitive:
• Feeling “In a Fog”, difficulty concentrating or
remembering, confusion
Emotional:
• more emotional, sadness
Signs and Symptoms
• Physical Signs
• Loss of Consciousness, Amnesia, motor/sensory
deficits
• Behavioral Changes
• Irritable, nervous
• Cognitive Impairment
• Slowed reaction times, memory or concentration deficits
• Sleep Disturbance
• Drowsiness, difficulty falling asleep
PCS Assessment/Referral
PHQ-9
GAD-7
Pediatric Symptom Checklist
Psychotherapy
Psychology
Psychiatry
Pediatric, Adolescent, Adult Medicine
Social Work
Mood Disruption
Headache Log
Vestibular Therapy
Physical Therapy
Relaxation techniques
Guided Imagery
Integrative Medicine Clinic
Neurology
Ophthalmology
Emotional,
Sadness,
Nervousness,
Irritability
ImPACT Testing
Pediatric Symptom Checklist
Somatic Symptoms Cognitive Symptoms Vanderbilt ADHD Scale
Migraine,
Driving Evaluation
Attention problems,
Headaches,
Memory
dysfunction,
Speech Therapy
Visual problems
“Fogginess”,
Dizziness/balance disturbance
Occupational Therapy
Fatigue,
Noise/Light sensitivity
Cognitive
Slowing
Psychology
Nausea
Neck Pain/Spine Pain
Psychiatry
Sleep Alterations
Neuropsychology
Difficulty falling asleep
Sleeping less than usual
Sleep Log
Sleep Specialist
Neuropsychological Testing
• Objective evaluation of function
• Baseline testing may be helpful
• Allows comparison of baseline to post-injury tests
• If baseline testing is not available, compare to agematched controls and a percentile generated
CDC
Heads Up – Brain Injury in your Practice
Facts for Physicians booklet
Acute Concussion Evaluation
(ACE) form
ACE Care Plan
Work version
School version
Concussion in Sports palm
card
MANAGEMENT OF
MILD TBI’S
Goals of post injury management
•
Prevent against Second Impact Syndrome
•
Prevent against cumulative effects of injury
•
Prevent presence of Post-Concussion Syndrome
•
Determination of asymptomatic status essential for
reducing repetitive and chronic morbidity of injury
•
Post injury: cellular metabolism is over worked, thus
the cells are more vulnerable to further insults and
injuries.
Management
•
•
•
Physical rest
“Cognitive” rest
•
Child needs to limit exertion with activities of daily
living and limit scholastic activity while symptomatic
•
Repeated injury or overstimulation during the energy
crisis of acute brain injury could lead to cell death
Pharmacology
•
Management of specific symptoms
Giza, Hovda. The Neurometabolic Cascade of Concussion. J Athl Train. Vol 36, p 228-235, 2001.
What is Cognitive Rest?
• Cognitive rest may also be called “brain rest”
• After a MTBI, we need to limit the activities that
use “brain energy” so that the brain can function
on the limited amount of energy it is creating.
• To help the brain heal and recover, some
cognitive activities need to be limited
temporarily.
What is Cognitive Rest?
• Some symptoms may worsen when engaging in
cognitive and physical activities. This is the
body’s way of indicating it is not able to make the
amount the energy being demanded, activity
should be stopped to allow body to rest.
What can be done on cognitive rest?
•
OK to watch TV, watch movies, and listen to music. The
volume should be low.
•
Go to school and do homework; however if school and
school work increases symptoms you may need
accommodations at school, shortened school days or to
stay home.
What is not allowed while on cognitive rest?
•
•
•
•
•
•
•
•
No computer activities
No video games
No recreational reading
No board games
No card games
No text messaging
No computer activities
No practicing musical instruments
What is physical rest?
•
Physical rest is limiting the amount of energy spent in
physical activity to allow the brain to use that energy to
heal.
What can be done on physical rest?
•
Walk with feet on the ground at a casual pace.
• Attend to school (no phy ed, gym class or recess).
What is not allowed while on physical rest?
•
•
•
•
•
•
•
•
•
No sports
No games
No practices
No gym/recess/exercise
No strenuous activity
No physical labor/work
No amusement park rides
No biking/skating/sledding/skiing
No jumping
School Accommodations
-
Approve dismissal for medical appointments related to
this injury
Reduced homework load. Limit to two hours maximum
for all subjects per night.
Limit computer time and reading requirements as
needed
Early dismissal/late arrival as needed
Extended time for testing, homework etc
School Accommodations
•
•
•
•
•
Eliminate non-essential work
Rest period in Health Office during day as needed
Wear hat or sunglasses for light sensitivity
Preprinted class notes
Utilize tools that address learning style: audio/video
recorders, computers, etc
How can your student receive
accommodations at school?
•
First identify the contact person at your school: advisor,
dean, principal.
• Alert the school and teachers of the injury as soon as
possible.
• Arrange a meeting with the school to discuss school
accommodations, bring in medical documentation.
Symptom Treatment
• REST!... the only known
effective treatment for a
concussion
• Encourage frequent breaks
from studying
• Encourage good hydration and
regular meals to avoid
dehydration and hypoglycemicrelated headaches
Student Athlete Management
• COGNITIVE REST
• If symptoms recur with
cognitive activity, time off
school may be needed
• Involve teacher, school
nurse, principal, coach
PCS Management
Antidepressants
Anxiolytics
Psychotherapy
Non-Pharm Headache Management
OTC: NSAIDs
Triptans
Beta Blockers
CCB
Antiepileptics
Antidepressants
Flexeril
Valium
Amitriptyline
Mood Disruption
Emotional,
Sadness,
Nervousness,
Irritability
Somatic Symptoms
Migraine,
Cognitive Symptoms
Headaches,
Attention problems,
Visual problems
Memory dysfunction,
Dizziness/balance
“Fogginess”,
disturbance
Fatigue,
Noise/Light sensitivity
Cognitive Slowing
Nausea
Neck Pain/Spine Pain
Amantadine* (off label)
Neurostimulants* (off label)
Sleep Alterations
Difficulty falling asleep
Sleeping less than usual
Behavioral: Sleep hygiene education, relaxation therapies, sleep schedule
Pharmacologic: melatonin, amitriptyline, trazadone, short-term use of nonbenzodiazepines
Pediatric Athletes (<18)
American Academy of Pediatrics (AAP) recommends
“conservative” management:
• NO return to play on same day
• Seriously, NO return to play on same day
• When in Doubt, Sit them OUT!
High school athletes’ and their
recovery from concussion
Collins M, et al. Neurosurg 2006
Return to Play
•
Normal imaging
•
Normal physical exam
•
Normal cognitive screen
•
Symptom free - Medication free (without activity)
Role of Physical Therapy for
Return to Activity
• Determine readiness to return
• Balance and vestibular assessments
• Stages for return to activity
DETERMINING
READINESS TO RETURN
TO ACTIVITY
Readiness for Return to Activity
• No adolescent with a concussion should continue to play
or return to a game after sustaining a concussion.
• Immediate Evaluation and Exam after a Concussion
• An individual sustaining a concussion should cease doing
any activity that causes the symptoms of a concussion to
increase (e.g. headaches, dizziness, nausea, etc.).
Readiness for Return to Activity
• If patients develop increased symptoms while doing a
specific activity, that activity should be discontinued.
• Continuing activities, or exercise that increases
symptoms, can delay the recovery from the concussion.
What are the risks of returning to activity
before an injury is healed?
•
Symptoms may last longer and become more intense.
• New symptoms may occur.
• Risk of repeat injury and risk of Second Impact
Syndrome.
Explain Risks of Premature RTP before
full recovery
• 2nd impact syndrome
• Death
• Higher risk in young
athletes
• 2nd concussion, more
severe
• Prolonged symptoms
Second Impact Syndrome
• In September of 2008, Jaquan Waller, 16, suffered a
concussion during football practice at J.H. Rose High
School in Greenville, N.C.
• A certified athletic trainer educated in concussion management
wasn't onsite, and the school's first responder who examined Waller
cleared him to play in a game two days later.
• During that game, Waller was tackled. Moments later, he collapsed
on the sidelines.
• He died the next day.
Second Impact Syndrome
• A medical examiner determined Waller died from what is
called second-impact syndrome, noting that "neither
impact would have been sufficient to cause death in the
absence of the other impact."
•
Read more: http://www.time.com/time/magazine/article/0,9171,1873131,00.html#ixzz1SegF8gRE
Discussion/Quiz
WHEN ARE PATIENTS
REFERRED FOR RETURN TO
ACTIVITY?
• No athletes should return to contact
competitive sports until they are symptom
free, both at rest and with exercise and
have normal neuro-cognitive testing.
• When they no longer have headaches or
other concussion symptoms athletes can
begin the concussion graduated return-toplay exercise program that was
recommended at the Prague Concussion
Conference.
Initial Evaluation
• Monitoring heart rate via use of a Polar Heart Rate
Monitor.
• A strap with the monitor is placed around child’s upper body
under chest and a watch is used to read their heart rate.
• Scapular/Cervical Screen
• Look at scapular (shoulder blade) alignment, upper extremity
antigravity movement and cervical Range Of Motion: looking
for symmetry & onset of cervical pain & substitutions
• Strength screen for cervical musculature:
• It is very common (especially for girls and women) to overuse
sternocleidomastoid (SCM) as compared to intrinsic musculature
of the neck
• Some evidence that cervical weakness contributes (or is at least
correlated with) repeat concussion in girls
• Look at chin tuck against gravity: any substitution with SCM?
• Check general isometric strength screen for cervical spine: looking
for cervical pain
BALANCE TESTS
BESS
• Balance Error Scoring System (BESS)
• Can be used by athletic trainers immediately following
concussion on the sidelines
• Utilized in the clinic as well to assess higher level
balance
BESS
• 6 testing positions
• All positions are preformed with eyes closed
• Each position is held for 20 seconds
• Count number of errors that occur
BESS Testing
Positions
Errors noted during the BESS
• Hands lifted off iliac
• Remaining out of
crest
• Opening eyes
• Step, stumble, fall
• Moving hip into more
than 30 degrees of
flexion or abduction
• Lifting forefoot or heel
off floor
testing position for
more than 5 seconds
• **The maximum total
errors for 1 testing
position is 10
errors**
BESS
• Insert Bess videos
Functional Gait Analysis
• Video
VESTIBULAR
EVALUATION
Vestibular Assessment
• Patients frequently complain of headache, dizziness, and
vision problems following concussion
• Oculomotor and Vestibular systems are assessed on all
patients at initial evaluation
What are the goggles?
• Infrared video goggles which help us to view eye
movements
• Allows for observation and video recording of eye
movements in both light and in the dark with the vision
occluded
• Simultaneously records audio (important for later
interpretation)
Real Eyes xDVR
Who is appropriate for the goggles?
• Patients from neurotrauma
clinic
• Patients complaining of
• Headache
• Dizziness
• Nausea
• Difficulty with
reading/schoolwork
• Referred for “balance and
vestibular testing only”
What tests are done with the
goggles on in the light?
• Saccades
• Vertical and Horizontal
• Smooth Pursuits
• Horizontal
• Vertical
• Diagonal
• Head Thrust
• Vergence
• Gaze Holding
What tests are done with the goggles and
vision obstructed?
• Resting nystagmus
• Following pts own finger,
while moved by therapist
• Hallpike Dix
• Headshaking nystagmus
Smooth Pursuits
• Hold finger or pen 18-24
inches away from face
• Ask child to follow slowly
moving object 30
degrees side to side and
up and down
• Normal: smooth,
conjugate eye
movements
• Abnormal: jerky or
saccadic
• Video Clip
• Smooth conjugate eye
movements
• Jerky or saccadic eye
movements
Saccades
• Hold finger or sticker 15
degrees to one side of
your nose
• Ask child to look at your
finger then your nose,
back and forth several
times
• Repeat right/left and
up/down
• Normal: <2 saccades
• Abnormal: >2 saccades
• Video of saccades
Head Thrust
• Sit in front of the child, holding their head in your
hands
• Warn the child you will be turning their head quickly
• Have the child fixate on your nose as you slowly turn
their head side to side
• Quickly and unexpectedly move the head to 1 side
• Repeat 2-3 times to each side of the head
Head Thrust
• Normal:
• Able to keep eyes on target
• Abnormal:
• Corrective saccade to move
eyes back to target
• Insert Video
Vergence
• Hold a finger or small toy 2 feet away from the
child
• Have the child maintain focus as you move it
closer to the nose
• Normal: Symmetrical convergence to the object
• Abnormal: Dysconjugate, asymmetrical gaze,
vergence response (point where object doubles)
>5 cm
Vergence
• Insert Video
Gaze Holding
• Have child begin by gazing straight forward
• Have them gaze in all 9 directions (think tic-tac-
toe board) holding each for 3-5 seconds
• Normal: No nystagmus, able to hold position
• Abnormal: nystagmus, rebound nystagmus,
inability to hold the position
Gaze Holding
• Insert video
Benign Paroxysmal Positional Vertigo
Assessment
• Hallpike Dix
• Done with vision obstructed
• Assess BPPV
• Have child long sit on mat with head turned 45 degrees to
one side
• Hold the child’s head keeping the rotation, then quickly lie
them down with head over the edge of the table in ~20
degrees of extension
• Ask patient to keep their eyes open and ask about their
symptoms
Hallpike Dix
• Insert video
Post Head Shaking
• Diagnoses an acute unilateral
•
•
•
•
•
•
peripheral lesion
Vision is obstructed
Grasp patient’s head and tip it
forward 30 degrees
Rotate the head 20 times at a
speed of 2 Hz
Stop and have the child look
straight ahead, keeping their eyes
open
Normal:< 2 beats nystagmus
Abnormal:>2 beats of nystagmus
toward more neurally active (intact,
healthy) side
Vestibular Assessment
• Based on results of oculomotor and vestibular screen,
patients are assigned home exercise programs
• Frequently done in addition to their graded return to activity
Return to Activity
Initial Evaluation
• We provide education to families on how to find target
heart rate during evaluation
• Karvonen Heart Rate
• 220 – Age = Maximum Heart Rate
• Maximum Heart Rate – Resting Heart Rate = Heart Rate Reserve
• Heart Rate Reserve x Training percentage + Resting Heart Rate =
Target Heart Rate
Onset of Symptoms during testing?
• During testing at the appropriate level, if there
is new onset of symptoms, the patient should
be cued to return to complete rest for 24
hours.
• Reschedule the patient for PT one to two days later
• At this visit, the patient can resume activity at the
previous level (i.e. doesn’t have to start over from
level I)
• NP/MD should be notified that symptoms returned,
and at what level of activity, as well as the plan for
return to PT
Return to activity
Stages for Return To Play
• No activity and rest until asymptomatic
• Stage 1: Light aerobic exercise
• Stage 2: Sport-specific training
• Stage 3: Non-contact drills
• Stage 4: Full practice drills except contact
• Student/Athlete will take final ImPact test and if
cleared will then return to full contact without
limitations
STAGE I
(Target Heart Rate – 30-40% of maximum exertion)
Athlete should be able to speak freely, not out of
breath during activities.
Limit head movement/quick position changes; limit
concentration activities
Stage I
ENDURANCE EXERCISES
(Should sustain for 15-20 minutes)
• Walking on Treadmill
• Nu-Step/ stationary biking
• Upper Body Ergometer (UBE)
• Pool (swimming laps/ swimming drills, front & back crawl)
• Stepping laterally or forward over cones
Stage I
Upper Extremity/ Lower Extremity Range Of
Motion
& Strengthening Exercises
• Lower extremity range of motion: Hamstring, Quadriceps
& Calf (if needed)
• Upper Extremity: low weight elbow (bicep) curls
• Standing calf raises
• Straight leg raises (Quadriceps) and sidelying hip
abduction/ hip extension (Gluteus Medius and Maximus)
Stage I
Balance Exercises
• Tandem stance position
• Single leg stance (eyes open & eyes closed)
Stage I
Cervical Exercises
• Cervical isometric exercises in all directions (do not do if
•
•
•
•
painful)
Cervical AROM exercises (slowly)
Scapular retraction in sitting or prone arms in 90° of
abduction
Pectoralis stretching at wall or over bolster
Cervical retraining with chin tuck in supine for stabilization
STAGE II
(Target Heart Rate - 40-60% of maximum exertion)
Athlete should be able to still complete a sentence
while performing exercises. Mild sweating.
Allow some positional changes & head movement;
low level concentration activities
Stage II
Endurance Exercises
(Sustain for 20-25 minutes)
• Brisk walking on Treadmill, possible interval jogging (walk
3 minutes, jog 2 minutes, then repeat)
• Elliptical
• Stationary biking
Stage II
Upper Extremity/ Lower Extremity
Strengthening Exercises
• Wall sits/ Squats/ lunges
• Basic Swiss ball core activities (abdominal
crunches)
• Side steps (small squat) with Theraband
around legs
Stage II
Upper Extremity/ Lower Extremity
Strengthening Exercises
• Leg press
• Step up/ down, lateral step ups
• “Bicycling in Air” abdominal exercise
• Can return to all static stretching positions
Stage II
Balance Exercises
• Single leg stance with lower extremity reach in star
•
•
•
•
pattern
Single leg stance on foam surface
Stepping forwards, sideways over cones
Tandem stance on foam surface
Begin activities with head movement
• Walking with head turns
Stage II
Cervical (neck) Strengthening
• Cervical extension in prone off table
• Cervical lateral flexion in side-lying
• Rotational crunches
• Prone (on belly) over ball with scapular (shoulder blade)
drills (“Y”; “swimming”; Bilateral ER starting in “goal post”)
STAGE III
(Target heart rate 60-80% of maximum exertion)
Athlete should be able to state a couple words
during activity.
Can start to incorporate exercises outside, can
begin to add concentration component to exercises
Stage III
Endurance Exercises (25-30 minutes)
• Jogging on Treadmill
• Ladder board drills (quick steps in ladder board) –
forward, sideways, in/out
• Elliptical or Stationary Bike
• Skipping or “Apple Pickers”, Carioca steps
Stage III
Endurance Exercises (25-30 minutes)
• Side shuffling exercises with verbal directional changes
• Short sprints & Zig Zag running
• “Running on Trampoline” (30-60 second intervals for
speed)
• Basic Jumping Drills (shuttle jumping, jumping off step for
form, single leg hopping)
Stage III
Upper Extremity/Lower Extremity
Strengthening Exercises
• Animal walking positions (crab walk, inchworm, bear walk
•
•
•
•
or duck walk)
Plank holds (in multiple directions)
Walking hands out on Swiss ball
Lunges in circular pattern
Sport Cord/ Theraband resisted lunges
Stage III
Balance Exercises
• Step over cones with directional changes
• Single leg balance with Upper Extremity star reaching
• Squats/ Lunges on Bosu disc
• Single leg stance on foam – toss ball at trampoline
Stage III
Cervical Strengthening
• Plyoball with crunches and drops (multiple positions)
• Holding crunch position drop/pass plyoball or weighted
•
•
•
•
ball to patient including with rotation
Rotational crunches with plyoball
“V” up
Kneeling on floor with elbows on therapy ball and
completing CW/CCW with trunk in neutral
• Human Rolling Pin
Any prior level cervical exercises
STAGE IV
(Target heart rate 80-90% of maximum exertion).
Athlete should not be able to state more than a couple words
at a time.
Continue to avoid contact activity, but resume aggressive
training in all environments. May return to non contact
practice activities if symptom free
Stage IV
Endurance Exercises
(Should be duration of 30 minutes)
• Treadmill running with interval sprints
• Plyometric drills (should do every 3rd day for plyometric
training principles & emphasize form & quiet landing)
• Box jumping on floor first with 2 feet & then progress to
box jumping with single leg (clockwise,
counterclockwise, diagonal)
• Single/ double leg jumping over line
• Jump up/ down step
Stage IV
Endurance Exercises (Cont.)
• Plyometric drills (should do every 3rd day for plyometric
training principles & emphasize form & quiet landing)
•
•
•
•
•
•
Box Jump with Drop
Single leg bounding
Tuck jumps
Side to side quick step over cones with holds
Side to side jumping over cones
Alternating lunge jumps
Stage IV
Endurance Exercises (cont.)
• Defensive shuffle with tennis balls for quick direction
change
• (Roll 1 tennis ball to R as athlete approaches ball roll
2nd ball to L, keep athlete moving quickly. Give athlete
goal of not letting ball travel past certain line)
• Dot Drills
• Running Stairs
• Sport specific activities (EXAMPLES)
• Soccer player – dribbling ball with cones, kicking ball
• Basketball player – running patterns with lay-ups
• Football player – running patterns with throwing ball
Stage IV
Upper Extremity/Lower Extremity
Strengthening Exercises
• Can return to all Upper Extremity/ Lower Extremity
strengthening exercises
• May return to lifting with team for upper and lower body
strengthening when/if cleared to do so (Including free
weights and machines).
Stage IV
Balance Exercises
• Continue to initiate sport specific balance exercises
• Single leg squats on Bosu disc (black or flat side up)
• Rebounder activities on Bosu disc
Discharge from PT
• PT will plan to discharge once the patient has passed
both maximal exertion and balance testing
Final Stage
• Athlete has now passed the final ImPact
test and has been given clearance by
provider for return to all contact drills.
• Recommendation: Have your
student/athlete participate in 3 full
practices including contact drills prior to
playing in a game situation.
Case Study #1 Vestibular
Case Study #2 Return to Activity
Conclusions
•
It is our responsibility to know what a
concussion looks like.
•
•
•
Concussions for young athletes are increasing
and underreported.
DO NOT RETURN ANY PLAYER TO PLAY THE
SAME DAY A SUSPECTED CONCUSSION
OCCURS.
Symptoms may not be reported by the athlete for
> 15’ so be very cautious if you suspect a
concussion.
Conclusions (cont.)
•
Young athletes who have a
concussion need to have complete
REST until symptom free.
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The most common symptoms associated with
concussions are headaches, dizziness,
“fogginess”, concentration/memory problems
Once symptom free then slowly return to activity
and monitor for any change in symptoms
ACCESS TO NT CLINIC
Gillette Children’s Neurotrauma Clinic
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What does an appointment entail?
Height/Weight
Nurse Appointment
Developmental Screening under age 6 years
ImPACT testing over the age of 10 years
Who sees the patient?
Neurosurgery Nurse Practitioner
Physical Medicine and Rehabilitation Nurse Practitioner
Members of the Neurotrauma Team at
Gillette Children’s Specialty Healthcare
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Physical Medicine
and Rehabilitation
Neurosurgery
Neurology
Physical Therapy
Occupational
Therapy
Speech Therapy
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Psychology
Neuropsychology
Social Work
Psychiatry
Sleep Medicine

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