7/18/18

Concussion is Treatable
Beginning Treatment the Day A7er the
Mechanism-Exercises

Randy Cohen ATC, DPT

Associate Athle9cs Director for Medical Services
University of Arizona

I have no financial conflicts with this presenta9on

Profiles/Disorders/Dysfunc9on/Deficits/
Subtypes to be determined by the
evalua9on
1) Ves9bular
2) Ocular-motor
3) Cogni9ve/cogni9ve fa9gue
4) Post-trauma9c migraine/headaches
5) Psychological Anxiety/Mood
6) Cervicogenic?


These subtypes are a work in progress and will
change by what we con9nue to learn.

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Re-thinking the term

concussion
•  Concussion induced trauma9c headache
•  Concussion induced cogni9ve deficit
•  Concussion induced oculomotor disorder
•  Concussion exacerbated anxiety issue
•  Concussion induced cogni9ve fa9gue
•  Concussion induced ves9bular ocular deficit
•  Concussion induced cervical sprain
•  Concussion induced exercise intolerance
More accurate- Concussion induced trauma9c headache,
ves9bular dysfunc9on and anxiety exacerba9on

Jus?fica?on for early treatment

•  Cerebellum will accommodate for abnormalities

•  Vestibular System accommodations can become ingrained

if not corrected early

•  DON’T IGNORE FATIGUE

Hypothesis for cause of orthopedic

injury a7er concussion
How systems work together
•  Vestibular Ocular
•  Ocular Motor
•  Vestibular Spinal
•  Cognitive
•  Cardiovascular
•  Energy systems

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Why do we have to train reflex?

•  Traditional balance training
•  Is balance a conscious
process?
•  Train the MOTOR PROGRAM

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Risk of Head/Neck Injury with

modifiable risk factors
•  190 Male rugby, Australian Rules FB
•  History of SRC & 5 measures of Sensorimotor Function
–  Balance
–  Vestibular function
–  Cervical proprioception
–  Trunk Muscle function
•  3/5 Risk Factors 14x greater risk of sustaining a season neck/
head injury (sensitivity 75% Specificity 82.5%) than player with
2/5 risk factors
•  Contraction of transversus abdominis muscle (asymmetrical)
was mediator in risk for future head/neck and was related to
previous injury.
•  Previous hx of concussion had smaller multifidus muscle

Hines et al. Self-reported Concussion History and Sensorimotor Tests Predict

Head/Neck Injuries ACSM 2017

Treatment
•  Rest- “Avoid any exacerbating activities”
•  Control known risk factors
•  Sleep Correction
•  Nutrition-Fuel the system during rehab, Fish Oil…
•  Don’t “shut down” areas that do not exacerbate
symptoms
–  if they can read and work on computer allow
•  Test for exercise tolerance and do exercise
•  Treat area of deficits found in evaluation
•  Treat areas at risk to develop deficits
•  Treat areas without deficit
•  Work the systems together

Be Crea?ve!!!!
•  Work Smooth Pursuits, Saccades, Vestibular Ocular Reflex,
Vestibular Motion Sensitivity, Cognitive Activation and
vestibulospinal system while they are doing Cardio Exercise,
Core stability Exercise, PRE’s, Functional Rehab then sports
specific/ADL specific activities

•  Work Dynamic Visual Acuity while they are doing activity

•  Expose Recover
§  Work just below level of symptoms

Most important- Understand Exercise Progression

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Dual Task Strategies

•  Combined postural control and cognitive tasks
•  Retrain executive attentional networks
•  Secondary cognitive activities improve postural
control (Wulf, 2001; Huxhold, 2006; Resch, 2011)

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Pencil Push Ups

Step 1
-Hold a pencil on front of you at arm's length. The pencil should
be ver9cal, with the 9p of the sharpened pencil at the top. The
pencil should be directly in front of your face, with the 9p just
below eye level.
Step 2
- Move the pencil slowly toward your face as you concentrate
and focus on the point. Soon you'll no9ce that you see two
pencils rather than one. Stop.
Step 3
- Look away from the pencil briefly to rest your eyes. Focus on
something across the room for two or three seconds, and then
look back at the pencil point where you've stopped it close to
your face. Look at the pencil point carefully, and to try to focus
so that the double vision disappears and you only see one
pencil.
Step 4
- Move the pencil back out to arm's length when you are able
to rid yourself of double vision. If this takes more than a few
seconds, look away and try again. Once you are able to
accomplish it, move the pencil back out to arm's length and
complete the exercise again.
Step 5
-Do the pencil pushups for 10 minutes, con9nuing to move the
pencil back and forth in front of your face. Talk to your
optometrist if the treatment doesn't help your convergence
insufficiency.

Push ups vision work

Reading Material on floor- Front/Side

Combina?on Oculomotor &

Cervicogenic
•  Increase symptoms with Oculomotor ac9vity
–  Posture, Heads stability?
•  Combined Cervical Stability and Oculomotor
ac9vity
–  Push ups with char9ng or reading material on
ground. Straight below or off to side

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Brock String

http://www.yourfamilyclinic.com/ND/vision/brock.html

Brock String
Talk to them during

Single leg stance during

Teach this to be
“reflexive” without need
to concentrate

Simple Hand to Hand Ball Toss

•  Can be Smooth Pursuits
•  Can be Saccades
•  Can be VOR Cancella9on

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Reac?on Time Training

with cogni?ve ac?va?on

Incorporate hand, eye, feet, core stability, head motion etc…

Sport Reac?on Time

Stimuli Seeing or Sensing

Recognize Stimuli

Reflexively &/or Cognitively React

Move Feet, Trunk, Head to correct position

Hands are in right position to do something

Reac?on ?me training in rehab

•  Progress to sport
specific training
•  Even if still having
symptoms
–  No risk of contact
–  Symptoms do not
increase with activity

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Track the ball. Catch both hand

Find ball-Catch- Track eyes back to

front

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Overhead squat-Saccades or Smooth

Pursuit

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TRAZER

Sport Specific Ac?vi?es

•  Soccer drills
•  Baseball Softball catch ball over shoulder
–  Start with knowing which way move to unknown
•  Basketball drills
•  Football drills

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Cogni?ve Ac?va?on of Reac?on

•  “Odd Right-Even Left”

•  8
•  3+5=

Time to play
•  Dynamic Balance
•  Balance with Flash cards
•  Ball toss and turn
•  Senap9c Glasses
•  VR Glasses Balance
•  Brock string SLS
•  Push ups into pencil
•  Balance with roller coaster VR

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