Mild TBI

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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.
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Mild TBI Concussion

• Assessment Treatment

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Dr. Barry WillerUniversity at Buffalo,
Concussion ClinicNHLBuffalo Sabres
FoundationOntario HockeyHockey CanadaSalt Lake
City Winter Olympics

• http//www.youtube.com/watch?vxXl6LPIoXUg

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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

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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

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How will our clients present?

• Headaches
• Photophobia
• Poor sleep
• Dizziness

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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.

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Quick Refresher

• 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

• 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

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Sympathetic Overdrive

• Imbalance between our sympathetic and
  parasympathetic nervous systems
• Parasympathetic system does not kick in
• Poor sleep hygiene
• Light sensitivity

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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

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Cerebrovascular Cardiovascular Benefits of
Exercise
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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.

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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

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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 significan
tly 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
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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?u
  bitbswiller
• http//concussion.buffalo.edu/
• bswiller_at_buffalo.edu

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Questions?