UPMC rehab program puts concussion patients back on track
July 30, 2008 4:00 AM
Brian Hagen, program administrator of the UPMC Sports Medicine Concussion Program, watches as high-level motocross racer Broc Hepler, a concussion patient, does physical therapy at the UPMC South Side complex.
By Pohla Smith Pittsburgh Post-Gazette
Broc Hepler, Kittanning's homegrown professional motocross star, figures he's broken 20 bones since he began riding as a kid, most recently an elbow and a finger, both of which required surgery.
But he doesn't consider any of them as big a deal as the concussion he sustained while training in California back in January 2007.
That one cost him four or five months of training and kept him out of racing for a total of six.
"I'd break any bone -- any bone -- over a concussion," he said last week. "A concussion is the worst."
His was especially bad, including seven minutes of unconsciousness and intracranial bleeding that kept him in a hospital for three days. The bleeding, not typical in a concussion, made his a more severe case.
Yet Mr. Hepler, 21, feels it might have gotten even worse if he hadn't flown home to the doctors and therapists of the UPMC Sports Medicine Concussion Program.
You see, there was a race coming up two weeks after his head injury, and he wanted to enter. The California doctors told him the risks of further injury but didn't specifically forbid him from trying to compete.
"They kind of said ... if you don't get too foggy, it's probably no problem to go ride," Mr. Hepler said.
But he did get "foggy" and made it through only two or three laps before he withdrew and said, "Let's fly home."
"It just shows the kind of doctors they were compared to those in Pittsburgh," he said.
Started in 2000
The sports center founded by Dr. Freddie Fu is world-renowned for many reasons, one of them the concussion program. Equal parts research and treatment, it was established in 2000 by Dr. Fu, who recruited from the Henry Ford Health System in Michigan Drs. Mark Lovell and Michael "Micky" Collins, both Ph.D.s, and neuropsychologists who are experts in the neurocognitive effects of sports-related concussion. Dr. Lovell is now director of the UPMC program and Dr. Collins, the assistant director.
While still in Michigan, the two worked with Steelers' team neurosurgeon Dr. Joseph Maroon to develop ImPACT, or Immediate Post-concussion Assessment and Cognitive Testing. ImPACT establishes an athlete's cognitive norm and allows for comparison with future ImPACTs after concussion and during recovery rehabilitation.
The concussion program has tens of thousands of baselines on file as ImPACT is used by Major League Baseball and MLB umpires, numerous National Football, National Hockey and National Basketball league teams, more than 360 colleges and universities, and more than 1,200 high schools.
Among the concussion center's newest innovations is a five-stage concussion rehabilitation program, which was outlined on the second day of the New Developments in Sports-Related Concussion Conference at the Sheraton Station Square last Thursday and Friday.
The treatment for concussion is rest, "but athletes need to be active," Dr. Collins explained. "If they're not, their mood changes, they lose conditioning, they feel frustration. But with that being stated, you don't want to push through it because [the concussion] will get worse. ...
"Three years ago, we wanted to create a program to retain conditioning but allow recovery from concussion. We began to scientifically explore the threshold they can handle during recovery so they don't become deconditioned ... so they'll be ready to go back" to their sport."
The result of the scientific research was the physical rehab program, which works in concert with the healing of the concussion as measured by regular ImPACTs. The program was outlined at the conference by one of its developers, Sean Learish, assistant director of physical therapy for the Sports Medicine center.
Back to normal
"The goals of the concussion rehabilitation are to complement medical and neurocognitive management and assist in returning individuals to preinjury activity level," Mr. Learish told the capacity crowd of 250 doctors, neuropsychologists and athletic trainers from across the United States and abroad.
Stage 1 is minimal exertion, like walking slowly on a treadmill, while raising the patient's heart rate to no more than 30 to 40 percent of the individual's maximum.
Stage 2 is light to moderate exertion, taking the participant to 40 to 60 percent of maximum heart rate.
Stage 3 is moderately aggressive, raising heart rate to 60 to 80 percent of maximum heart rate, and Stage 4 is regular sports performance at 80 to 90 percent maximum heart rate.
Stage 5 is full exertion sports performance with contact.
During this five-phase process, the physical therapist takes and updates a history on the patient, including ImPACT scores, goals, symptoms history, current symptoms and medications.
"The rate of progression varies," Mr. Learish said. "You've got to treat each guy differently. It's also dependent on goals. You can go slow if returning to the sport is not the immediate goal."
Mr. Hepler wanted to return to racing, but the Concussion Program staff made it clear it wouldn't be soon.
"Dr. Collins actually warned me it could take two months or three years," Mr. Hepler said. The doctor said he might even have symptoms like headaches the rest of his life.
"I probably did one month of nothing, actually closer to two months," Mr. Hepler added. His brain still was so traumatized that after driving the 100 miles round trip between Kittanning and Pittsburgh he would need to sleep several hours. Playing a video game had the same effect.
When he finally did start physical rehab all he did was walk the treadmill at about 21/2 miles per hour. "That was all I could do on it. I couldn't get my heart rate above 120 without getting symptoms [of fogginess, or slower comprehension]," Mr. Hepler said.
In comparison, he explained, "Your heart rate ranges from 180 to 200 for 30 minutes in a bike race."
From there Mr. Hepler progressed steadily through the next four phases Dr. Learish described at the concussion seminar. In the final two phases he did exercises that simulated the actual movements of riding a dirt bike. They were designed for him by Dr. Brian Hagen, Ph.D., head of outpatient physical therapy at UPMC Sports Medicine and a former casual motocross rider.
In one, for example, Mr. Hepler was attached to elastic belts that stretched from the ground level to his waist while he jumped forward, backward, sideways and diagonally. He did the exercise holding a soccer ball between his legs to imitate the feel of a bike and gripped a piece of PCP pipe to simulate holding the handle bars.
"That's a really difficult exercise when you're coming back from a concussion," Mr. Hepler said. "That was a really good test to see if I was still making progress and getting better."
Mr. Hepler still does that exercise just to keep in shape between races.
"That's why I come back to Pittsburgh for all my injuries," he said.