Aerobic Exercise Speeds Concussion Recovery

The recommendations for activity following concussion have been changing with the current guidelines being a shorter period (24-48 hours) of rest following injury.  We are now finding that this shorter period of rest and early subthreshold aerobic activity are beneficial in speeding recovery after concussion.

A recent study by Leddy et al looked at adolescent males who came to a concussion clinic less than 10 days from injury.  They were grouped into an exercise and rest group.  The exercise group completed the Buffalo Concussion Treadmill Test (used to determine an appropriate submaximal heart rate) and performed 20 minutes of exercise daily on the bike or treadmill.  This was compared to the group that was advised to completely rest from physical activity.  The exercise group recovered in mean of 8.29 days from initial visit and 13.04 days from day of injury.  The rest group recovered in 23.93 days from initial visit and 28.43 days from day of injury.  These findings indicate recovery time from initial visit was significantly faster for the exercise group.  Also, none of the exercise group participants had delayed recovery (>30 days of symptoms) while four participants in the rest group had delayed recovery. From day 4 forward the exercise group had a significantly lower total symptom score compared with the rest group. 

This study is an excellent start in support of early subthreshold aerobic exercise following concussion injury.  The study also had some interesting discussion about the benefits of aerobic exercise including:

·         Enhances neuroplasticity acutely to promote neuron growth and repair

·         Reduces heart rate at rest and reduces submaximal exercise heart rate by reducing sympathetic activity

·        By improving Autonomic Nervous System balance aerobic exercise may also improve sleep (a big deal in many patients after a concussion injury)

The recommendations continue to move towards a more active approach to concussion management.  A Physical Therapist can assess you and help determine the appropriate prescription for aerobic exercise since too much can exacerbate symptoms and delay recovery. We say this for so many other types of injuries in Physical Therapy and now we can also apply it to concussions…Exercise is Medicine!!!

Leddy JJ, Haider MN, Hinds AL, Darling S, Willer BS. A Preliminary study of the effect of early aerobic exercise treatment for sport-related concussion in males. Clin J Spsort Med. 2018;1-8.

Return to Sport Following Concussion-New Research on Exertion Testing

If you have gone through concussion therapy at Next Level you are probably familiar with strapping on the heart rate monitor and getting your sweat on with exertion testing and training.  Now the research is starting to take a closer look at intensive and dynamic exertion testing and its importance in the return to play process.

A recent study published in October 2018 looked at using a new concussion exertion protocol called the Gapski-Goodman Test (GGT) developed by the Chicago Blackhawks medical staff.  This test was designed to help with clearing athletes as one piece of the return to play process following a concussion.

Currently the most researched physical exertion test has been the Buffalo Concussion Treadmill Test (BCTT).  This test (as described in the name) is performed on the treadmill with increasing difficulty through a progressive increase in incline.  The BCTT tests aerobic capacity in a single linear direction only which may not be provocative enough to reproduce symptoms in high level athletes. As stated in this current study, “The BCTT, therefore, may not provide an adequate challenge to all physiologic, vestibular, and oculomotor systems necessary for athletes returning to anaerobic and dynamic, multiplanar, high-risk contact sports"¹ The GGT in comparison has been created to provide “alternating aerobic and anaerobic states in addition to sport-based vestibular and vision challenges designed to mimic a dynamic sporting environment.”¹

The study found that while 100% of the athletes successfully passed the BCTT, 14.6% had an exacerbation of symptoms with the GGT (or modified GGT). The study discusses how the GGT with its more intensive and dynamic exercise selection potentially tests the vestibular and oculomotor and anaerobic systems more thoroughly than the BCTT.  This is important because these systems must be functioning properly for safe return to the unique challenges of sports.

New research is taking a closer look at testing similar to what we have been doing here at Next Level: dynamic, intensive, and sport specific exertion testing and training

It is exciting to see this dynamic form of exertion testing emerging in the research.  It is possible for patients to feel symptom free before they are fully physiologically healed after a concussion. Exertion testing therefore can play an important role in making sure we stress these systems to mimic the demands of sport to ensure symptom free and safe return to play.  

Here at Next Level we use a combination of testing depending on the severity of your symptoms.  We may perform the BCTT which can be extremely helpful in establishing a target heart rate for beginning aerobic training.  As vestibular therapy progresses, we monitor for when it is appropriate to begin dynamically challenging the systems with more intensive exertion testing and training.  We have utilized very similar testing to the GGT and incorporate coordination and reactive drills that are sport specific as needed. 

When working with your doctor to obtain clearance for full return to play exertion testing and training are one useful part of the evaluation and treatment process.  We will be keeping an eye on the future for further research supporting exertion training!  And in the meantime we will keep the heart rates up and the sweat going as we help athletes recover and return to sport. 

11.)    Marshall CM, Chan N, Tran N, DeMatteo C. The use of an intensive physical exertion test as a final return to play measure in concussed athletes: A prospective cohort. Phys Sportsmed.2018;1-9.

Is there a higher risk of lower extremity injury after a concussion?

By Kirsten Carmichael DPT, CSCS, SFG I, MFDc

I always have my eye out for the latest research in the world of concussions and some very interesting studies have been emerging lately. The question being asked is do athletes have an increased risk of sustaining a lower extremity injury following a concussion?

One study by Lynall et al in 2015 retrospectively looked at injury data in Division I collegiate athletes.  They found these athletes were almost twice as likely to experience lower extremity musculoskeletal injury after concussion when compared with controls.

Another more recent study in May 2017 found similar findings with collegiate athletes.  Herman et al reported that the odds of sustaining a musculoskeletal injury were 3.39 times higher in the concussion athletes.

Yet another recent study by Lynall et all published in November 2017 looked at high school athletes. This study found that for every previous concussion, the odds of sustaining a subsequent time-loss lower extremity injury increased 34%.

So, what gives with all this increased injury risk?  It is suspected that lingering deficits in gait and dynamic balance may have something to do with it.  Lynall et al has proposed there may be reduced cortical excitability impairing the brain’s ability to effectively control and coordinate movement after concussion.  Further, this may have something to do with delayed reaction and movement time.  If we think about this in relation to the high physical and cognitive demands of athletics it is easy to see where the potential for injury may occur.

With this information how do we make a change to help lower the risk?  Currently many concussion protocols primarily utilize neurocognitive testing, static balance tests, and symptom reporting.  It is proposed that utilizing more functional balance assessments would be beneficial (especially using sport specific tasks such as cutting and jumping).  This sounds a lot like what I do at Next Level in my exertion assessments.  During an exertion evaluation the athlete completes multiple dynamic tasks testing the vestibular system at high levels and elevating the athlete’s heart rate.   We consider the specific nature of each sport and look to progress all aspects before return to play including cutting, changing direction, accelerating/decelerating, jumping, running, throwing, coordination, reaction time, and cognition.  The goal of future research will be to take a deeper look at functional movement after concussion and come up with a dynamic assessment that is easy to implement in our concussion protocols across all levels of athletics.

Exertion Physical Therapy-where we jump, cut, change direction, and get sport specific :)

My take home message from this research is that concussions are something that should be taken seriously for many reasons.  If you have a concussion it is important to get evaluated to make sure everything clears (including those dynamic balance and sport specific tasks) before returning to sport to avoid the risk of musculoskeletal injury.  Hopefully soon everyone in athletics will have more detailed assessment tools and we can see the incidence of these injuries go down.

References

Lynall RC, Mauntel TC, Padua DA, Mihalik JP. Acute lower extremity injury rates increase after concussion in college athletes. Med Sci Sports Exerc. 2015;47(12):2487-2492.

Herman DC, Jones D, Harrison A, et al. Concussion may increase the risk of subsequent lower extremity musculoskeletal injury in collegiate athletes. Sports Med. 2017;47(5):1003-1010.

Lynall RC, Mauntel TC, Pohlig RT, et al. Lower extremity musculoskeletal injury risk after concussion recovery in high school athletes. J Athl Train. 2017;52(11):1028-1034.

Post Concussion Physical Therapy

By Kirsten Carmichael DPT, CSCS, SFG I, MFDc

How does a Physical Therapist help someone post-concussion?

Most concussions (80-90%) will resolve within a 7-10 day time period.  For a small percentage of people symptoms last beyond 2-3 weeks and in these cases a Physical Therapist may be able to help.

The vestibular system located in the inner ear senses motion of the head and helps stabilize your eyes while you are in motion.  If the vestibular system is disrupted you may continue to experience dizziness, sensitivity to motion, difficulty balancing, etc. 

Testing eye movement during an evaluation

A Vestibular Physical Therapist can provide a detailed assessment to determine the nature of your symptoms and begin exercises to help the system adapt and heal. 

Training convergence with a Brock String

Balancing on an unstable surface and getting in some rotational work

A Physical Therapist can also address any underlying issues with the neck that may present with a concussion.  It is always important to assess if dizziness and headaches are actually coming from the cervical spine.  We also initiate cervical strengthening exercises as early as possible.  Strengthening the neck has been found to reduce the odds of concussion which is important when returning to sport.

Working the scapular muscles and strengthening the neck wearing a special cervical weight

 Research has also found that getting moving as soon as possible after a concussion is important.  With exertion therapy we monitor you through a progressive and sport specific return to play program. We work with your doctor to make sure you are ready to return to sport. Additionally, we make sure you have regained your strength, agility, plyometric, and reaction time to prevent any future musculoskeletal injury.

Heart rate monitor on and ready to get moving on the Airdyne bike

Working on some dynamic stability training

  Higher level training challenging the vestibular and cardiac systems in multiple                                    planes

If you are experiencing lingering concussion symptoms contact us and see what we can do to help you get back in the game!