THE UTILITY OF A MULTIDIRECTIONAL SUBMAXIMAL EXERTIONAL STEP AS PART OF AN EXERTIONAL REHABILITATION PROTOCOL AFTER CONCUSSION. Issue 7 (30th July 2021)

• Record Type: Journal Article
• Authors: Paulsen, Katelyn; Johnson, Kyle; Marx, Tyler; Minor, Jon; Streeter, Leslie; Pita, Monica; Braden, Gaige; Frino, Libby; Peterson, Erin; Handmaker, Hirsch; Mortazavi, Mo
• Is Part Of: Orthopaedic journal of sports medicine. Volume 9:Issue 7(2021)Supplement 3
• Publication Date: 2021-07-30
• Subjects: Sports medicine -- Periodicals; Orthopedics -- Periodicals; Arthroscopy -- Periodicals; Arthroplasty -- Periodicals; Knee -- Surgery -- Periodicals; 616.7
• DOI: 10.1177/2325967121S00101
• Languages: English
• ISSNs: 2325-9671

Abstract

Background: This study aimed to identify whether a 5 Step Exertional Rehabilitation Protocol including a submaximal multi-directional stage (Step 5) has clinical utility for functional activity and sport clearance. Exertional Rehabilitation (EP) is a graded protocol of aerobic exercise ranging from light linear exertion (Step 1) to submaximal linear exertion (Step 4) 1, 2 . In our 5 Step Protocol, Step 4 is followed by standardized multi-directional functional movements at high intensity intervals (Step 5) to rule out ongoing exertional intolerance. Hypothesis/Purpose: We aim to investigate if Step 5 testing demonstrates statistical evidence for its use in determining concussion recovery timelines and its diagnostic usefulness. Methods: This retrospective-chart review analyzed 60 Step 5 EP test attempts in post-concussion patients, ages 21 or younger, between Jun2019-Jun2020. Tolerance was determined by a concussion specialist who evaluated for the onset of signs/symptoms by surveying the patient throughout exercise and autonomic assessment with cardiac monitoring and pre/post orthostatic testing. Pre/Post exertion King-Devic (K-D) and vestibular testing on Force Plate were completed following Balance Error Scoring System positions. A positive change in K-D was defined as a ≥2 second delay in score on two of three reading cards from the pre-exertion testing. A positive change in vestibular testing was defined as a ≥0.2deg/sec change in the composite balance score from the pre-exertion testing. Results: The total number of failed Step 5 attempts was 21.7%. Of the failed attempts, 38.5% demonstrated dysautonomia, 92.35% had symptoms, and 30.8% demonstrated both dysautonomia and symptoms. Force Plate balance scores significantly worsened in failed attempts 15.4% of the time while passed attempts only 2.1% of the time. K-D scores did not show a statistically significant difference although failed attempts did have slightly worsened scores. Conclusion: Formal Step 5 testing is a useful diagnostic tool for understanding recovery stage, activity tolerance, and sport clearance. Autonomic, visual, and vestibular testing can be useful as objective markers of test tolerance. Tables/Figures: Figure 1.1. Figure 1.2. Citations: 1) Leddy JJ, Haider MN, Ellis MJ, Mannix R, Darling SR, Freitas MS, Suffoletto HN, Leiter J, Cordingley DM, Willer B. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019 Apr 1;173(4):319-325. 2) Gagnon etal. Another look at active rehabilitation for slow-to-recover sport-related concussion in children and adolescents: further evidence to support its effectiveness. BJSM, 2013.