[Expert Physio Q&A] Return to play after concussion with Dr Brooke Patterson

0:00There is some preliminary evidence from our prep to play trial. Hopefully publish this year sometime that does reducing concussion as well and the more that teams use the program, the more in all injuries reduced so that kind of dose response effect which is good but obviously they only work if you do them so I do strongly believe that we need especially in Australian football when I think especially in juniors and especially in female women and girls who are already playing a little bit catch up with some of these skills. That's the biggest area for like improvement is actually practicing the technique and getting them doing it training. Welcome to another expert Q&A episode. Today we're sharing a highlight from our recent session with Dr. Brooke Patterson, physiotherapist and research fellow at Latrobe University's Sport and Exercise Medicine Research Centre. Brooke's postdoctoral work focuses on reducing knee injuries and concussion in women's AFL and she played a leading role in developing

1:04the prep to play injury prevention program. In this episode Brooke impacts the crucial topic of return to contact after concussion, drawing on both research and clinical experience. You'll hear key insights into prevention management and how she safely guides athletes back to contact sport. Remember practical subscribers get live access to these Q&As with experts like Brooke, plus the chance to ask their own questions. We hope you enjoy the conversation. Hi everyone, my name's Sarah and I help run the Q&As for Physio Network and I'd like to start by welcoming Brooke who is here tonight to answer some of the questions that have been submitted about her fantastic practical. So welcome to you Brooke and thanks again and I hope you all enjoy the session and we might kickstart with our first question, which is do you retest, scat or other outcome measures during the return to play process?

2:05That's a great question and not usually so the scat has kind of limited utility is like a return to play tool beyond that kind of acute phase like really within the first seven days. So it's a tool and this is advice from the like international consensus statement on sports related concussion. So the scats like really good at discriminating between people that can cast a non-cast in that first 72 hours, but a lot of the tests actually have ceiling effects and unless you actually have like a baseline test of that athlete, which might be, you know, you might have that in the lead setting, but in a lot of settings you might not have that. So you don't actually know like what is normal for some of those tests. So it's a little bit tricky to use. I guess the main thing at that return to play, you know, what you're reassessing is that they're symptom free. So the scat might be helpful in terms of just refreshing yourself of those potential symptoms that they initially presented with and making sure that those things are not still there and maybe crowding about some of

3:08those things. Yeah, the main thing is that they actually can just progress through their activities that they need for sport and the graded return, you know, symptom free and these are kind of really our best test at that end stage. Just on that any other outcome measures that you would retest in that return to play process. I would be making it very sports-specific in terms of them hitting their like intensity of their training that also kind of I guess if the training isn't designed to kind of really test them out for those game like scenario is that you might need to be a little bit more prescriptive in really challenging them physically, but also cognitively and throwing in a few different kind of complex drills and tasks. All right. Question number two, do you include any next specific strength or exercises when working with athletes post concussion? I thought this always comes up with the topic of concussion I think. So mainly if I start with the evidence for next strength and also next strength for Neen is an intervention

4:10and then going to maybe some clinical kind of recommendations based on that evidence. So the evidence for next strength as a risk factor for say, hitting packs and concussion is very meek. So there's a handful of studies that would show an association. If you have weak neck muscles, you're at an increased risk of having a head impact for a concussion and then there's also a handful of handful of studies that show that there's no association there and as the listeners might appreciate these studies are very difficult to conduct. You need a large sample, you need people to go on to have their hands back to injury and there's so many confounding factors like previous injury, the type of sport. So very tricky to know whether it's an important factor that we can modify to prevent concussion. You know, theoretically it's plausible that if you have good strength and control of the neck, those muscles do play a key role in stabilizing the head and resisting those linear and rotational accelerations. So I think theoretically it's there,

5:10but we need a little bit more research in terms of the evidence for next strength thing. So for all in like all injuries, risk factor studies are like so hard to do and actually we just can't do the intervention and test that and see if it works is sometimes the best way to kind of get to the answer. Again, there's pretty conflicting results there for the effect of next strengthening. So there's lots of studies that have say added next strengthening to the fee for 11 plus. A lot of studies in soccer also doing like heading training. So a little bit more kind of sports specific kind of neck control. Again, a handful of studies show it's a fett of a handful that haven't shown any effect and they use their exercises in these trials and kind of part, some of them are more pilot studies and not randomized controlled trials either. They are either kind of isometric holds of the neck. Some of them are more like dynamic exercises like kind of falling and rolling backwards and controlling the neck. There has been a couple of studies that show luck if you do next strengthening

6:11obviously your neck gets stronger and also that it does do a better job of resisting some of those acceleration events, but not really that many have shown does it then go to the next step of preventing concussion. So I know that probably doesn't help the listeners very much to say that there's no evidence or I'm very much sitting on the fence because the evidence is sitting on the fence. But you know, if we take that into account, there's clearly something there or what would be that like I guess clinical recommendation from that anecdotally, I know a lot of elite programs, especially in those contact codes are doing neck strengthening, you know, it can be from isometric to more isotonic fast flow strength movements plus some reactive strength. So I think it definitely is a consideration and so there's nothing I don't think lost in in doing it. If it's something you're considering, I'm not aware of any kind of adverse events from any of these studies. Of course, if you do anything a little bit to the heart or challenging you might get sore from it, you know, the only thing that's probably lost is time and especially in communities for where, you know, we even struggle to

7:16get a neuromuscular training warm up implemented and then you're getting them to do kind of static neck holds and things. It's a challenge with the implementation piece I think. So I think we probably need a little bit more evidence to be going and saying to particularly community sports teams, you need to be doing neck strengthening for concussion, especially because a lot of the good strengthening does require a little bit of like equipment set up as well. There has been in community male rugby and neuromuscular training program where they do a little bit of kind of core strengthening that's very specific to like the scrum positioning, kind of four point nudes and holds and things like that that has been shown to reduce concussion rates. So there's only one studying kind of that youth male rugby that is showing that. So there's potentially some of the other elements of the neuromuscular training programs that might help prevent concussion whether that's just the general core strength plus some of the spatial awareness and body awareness and balance and things like that. Once an easy way to improve your assessment and treatment skills

8:22introducing practicals where you can watch video recordings showing exactly how top experts assess and treat a range of conditions. It's the fastest way to develop your practical skills and enhance your clinical reasoning. Treat your patients like the experts do with practicals by physio network. Click the link in the show notes to try it for free today. The next question is can you please talk about the pre-contact phase so where the athlete is returning to general aerobic exercise and what are the guidelines and how would you structure it? Yes, so this is very specific to the particular protocols. I will just say for anyone listening in look up your own like the sport that you're dealing with and they're protocol because they do all slightly differ a little bit. And if you don't, if there's no kind of sport-specific guideline then you kind of then your next best option is going to kind of the Australian sports condition or more general guidelines from say sports members in Australia or all the APA and things like that for a little bit of guidance. But they're all within the same realm of

9:25those progressions. This is the AFL graded return to play so stage one in this protocol is relative rest so if the injury happens on a summer day at footy you know definitely the rest of the day the next day potentially even the Monday it's gentle day-to-day activities so minimizing that screen time so that might mean a day off school and minimizing phone time on the Sunday and Monday and yeah taking it fairly easy some short walks would be fine and then they can progress after one to two two days of that so there's kind of no more sitting at home for a week a week off school laying in bed for a week. The evidence would suggest actually kind of getting moving as long as symptoms are not worsening so they can have some kind of mild symptoms in this next recovery phase so as long as when they do their you know this next activity that their concussive symptoms don't really increase more than kind of a two out of ten from what

10:26it was previously and if it does then they kind of have to stay at that phase so if yeah the injury was on the Saturday rest day on the Monday short walks and then you know they might come along to training then on the Tuesday and this is where they can go into their light aerobic phase so max heart rate of 120 no skills and it might be just either a walk jog or a bike one minute on one minute off for 20 minutes the most kind of community athletes that would be something suitable they can come along walk around watch training for a little bit and then probably not hang around for the whole night head home and and rest up and then the next would be so if they get through that okay then they can go to that moderate aerobic and they have to spend at least two days in this moderate aerobic stage you know they might not be coming along to training so it might be prescribing them something that they can do on their own like a moderate intensity bike session or bike ride where they can go to that you know six you 80% maximum heart rate and then

11:30I've just got a suggestion here so five times one minute on two minutes off or like a 15-minute steady so if they're doing two days of moderate aerobic one of them I would say a bike and then the other one I would get them to do some kind of run through so this would just be an example five two hundreds at six to eight percent and doing two sets of that and then doing two five minute runs keeping that heart rate in that range all going well if their symptoms you know haven't gone back haven't worsened this is just an example case study here they've got their headaches completely you know they had a five out of ten then it was a two out of ten when they did their lighter aerobic but stayed two out of ten in the moderate aerobic which is okay and then that kind of disappeared from then on so then the higher aerobic they can start doing a bit of moderate intensity gym but around up to 70% of their usual weight and then a run might be up to max heart right now so that has to be athlete appropriate you know this was I was speaking to a group of kind of community junior senior football as I was kind of around four to five kilometers for

12:34training sessions some intervals plus some volume make it kind of specific to what they would normally cover in a training session and then you know give them a bit of a rest this is when they're entering into that stage three so if I just go back to this once they get to the end of this recovery period they do have to have those complete symptoms gone remember so yet has to be zero out of ten for all of their symptoms before they but can do non-contact training so that's this phase now so they can keep doing their gym and progressing up to their normal resistance and then coming into non-contact skills and drills and their run program for their first session back maybe a gym awesome cross training would be a rest and then another session of the non-contact drills the same as and then it's a week of this so minimum seven days for this is for the AFO program that they have to be in mid-risk right at the bottom here they have to be in non-contact for a minimum of seven days and then this is that final phase where they're going to some limited contact drills they need to have that review and clearance for their

13:38return to full contact training from a medical practitioner then they can go into full contact training and return to play on day 21 so this limited contact is a is a quieter AFO specific a lot of the other protocols don't have that what that means is some of those things are showing in that the practicals so not going into competitive 3v3 games it's it's more you know introducing to like one-on-one contact either with like a coach or a pizzo or a pier whether that was some centacling or some competitive grambles or competitive aerobols or whatever the sport might be so just kind of you know controlled manner to see how they respond to that you know initial contact before they're going into the really competitive stuff hopefully that helps lay it out we're sort of touched a little bit on this but the last question is is there evidence to suggest that program such as the one demonstrated in your practical do actually reduce further concussions great question and yeah I think I kind of mentioned that the only actual published study

14:40that's shown to reduce concussions from a neuromuscular training warm up program is in community youth boys rugby so yeah study by his slot and colleagues it's the activate program so if you look up the rugby activate it's all on the world rugby page you can see some of their exercises but they're very similar to kind of an wee base prep to play on that that program and and others like the 11 plus and you know other programs in Canadian basketball rugby as well volleyball so only one study but there is some preliminary evidence on our prep to play trial hopefully publish this year sometime that does reduce concussion as well and the more that teams use the program the more in all injuries reduce so that kind of dose response effect which is good but obviously they only work if you do them so we still don't know what the critical kind of elements are or what the dosages required but I think definitely getting them doing you know high fidelity exercise neuromuscular

15:41training exercises I think the contact elements of prep to play were probably where we had the biggest change in coach behavior so there's a lot of fear from coaches and players and parents that you know we don't want to do these things are training because of the risk so actually what of a lot of our program was actually more empowering and showing them safe ways to do it in a controlled manner and then build up from there and that's actually where we have the biggest bind from the program and uptake of the program because it's you know they footy drills as well so it was a little bit easier to sell than you know neuromus your warmer and whispering at the end of training so I do strongly believe that we need especially in Australian football when I think especially in juniors and especially in female women and girls who are already playing a little bit catch up with some of these skills that's the biggest area for like improvement is actually practicing the technique and getting them doing it training as opposed to probably what we hear out of the NFL and American football and that where the sports just it's all that collision contact tackling so I get that in those sports there they've got some guidelines and rules around

16:44and there is some evidence in American football where they've reduced the contact load in train and that reducing the risk of you know concussions in training and in games but I think that's a completely different sport and context and actually in most other sports like Australian football and headings and that whole another you probably should get heading in for a whether we should be bang heading or actually training heading in a controlled manner yeah saying honoured concept I think. Rook that was very helpful this evening and thank you to everyone that has joined tonight and this will also be uploaded so you can also listen to the recording later on. Thanks very much for jumping on everyone enjoy the rest of the night.