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.
Mild TBI & Concussion
Assessment & Treatment
Dr. Barry Willer
University at Buffalo, Concussion Clinic
NHL
Buffalo Sabres Foundation
Ontario Hockey
Hockey Canada
Salt Lake City Winter Olympics
 http://www.youtube.com/watch?v=xXl6LPIoXUg
Definitions:
o 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
o 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
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
How will our clients present?
 Headaches
 Photophobia
 Poor sleep
 Dizziness
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.
Quick Refresher
Sympathetic Nervous System
Parasympathetic Nervous System
↑ HR
↓ HR
Pupils dilate
Pupils contract
Inhibits digestion
Stimulates digestion
Inhibits nasal secretions
Causes nasal secretions
Inhibits saliva production
Stimulates liver/kidneys/gall bladder
Inhibits liver/kidneys/gall bladder
Causes constriction inside the lungs
Stimulates sweating
Causes piloerection
Makes lungs dilate
↑ muscle strength
i.e.
“fight or flight”
vs
“rest and digest”
Sympathetic Overdrive
 Imbalance between our sympathetic and parasympathetic
nervous systems
 Parasympathetic system does not “kick in”
 Poor sleep hygiene
 Light sensitivity
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
Cerebrovascular & Cardiovascular
Benefits of Exercise
↑ PNS
activity
↑ Autonomic
regulation
↓ Depression
EXERCISE
Improved
sleep
Improved
mood
↑ cerebral
blood flow
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.
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
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 Syndrome
John 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
References
 http://www.medicalnewstoday.com/releases/53995.php
 http://journals.lww.com/cjsportsmed/Fulltext/2011/03000/Reliabili
ty_of_a_Graded_Exercise_Test_for.3.aspx
 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
 A Preliminary Study of Subsymptom Threshold Exercise Training for
Refractory Post-Concussion Syndrome
John 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
 http://medicine.buffalo.edu/faculty/profile.html?ubit=bswiller
 http://concussion.buffalo.edu/
 bswiller@buffalo.edu
Questions?