Title: Comprehensive Physical Therapy Evaluation and Treatment of patients with concussion

Background: Concussion is an injury that is increasingly recognized as a public health concern. Concussions can result from sport-related injuries, work-related injuries, combat-related injuries, or can result from car accidents or falls. Despite advancing in imaging and biomarkers research, the diagnosis of concussion remains a clinical diagnosis based on multifaceted assessment approach. A considerable percentage of patients with concussion develop persistent symptoms and persistent impairments that warrant proper identification and treatments. However, persistent post-concussion impairments are heterogeneous and can fall under various clinical pathways, making it challenging to manage in a clinical setting. This workshop is designed to educate rehabilitation providers on proper identification and management of patients with concussion including management of patients with persistent impairments. This workshop will also address various strategies to ensure successful return to sport, military duty, work, or return to school.

Learning objectives: By the end of the workshop, attendees will be able to:

• Understand the role of various providers in the interdisciplinary management of concussion.
• Recognize patients who have developed or at risk of developing persistent symptoms after concussion.
• Understand the evidence surrounding the utility of different tests in the diagnosis and prognosis of concussion.
• Recognize the appropriate recommendations for acute management of concussion based on the most recent international guidelines and consensus statements.
• Recognize the various post-concussion clinical pathways including vestibular system dysfunction, ocular alignment and ocular control dysfunction, cervical spine impairments, cognitive impairments, migraine, and anxiety.
• Master screening tools utilized to identify impairments in each of the above six mentioned categories.
• Master and implement treatment options for each of the above-mentioned impairments; with special emphasis and hands-on practice of interventions to target cervicogenic, vestibular and ocular motor impairments, and patients with overlapping impairments.
• Recognize the step-wise approach needed in treatment of concussion prior to work, sport, military duty, or return to school.

Dr. Alsalaheen is an Associate Professor and a clinician-scientist at University of Michigan, USA. Dr. Alsalaheen has extensive research and clinical experience in management of sport-related concussion. His research focuses on developing comprehensive approaches to understand variations in concussion risks, recovery times, and rehabilitation outcomes. To date, his research has resulted in more than 25 peer-reviewed publications employing a variety of laboratory, translational and clinical designs with emphasis on knowledge translation and implementation science.

In addition to his research experience, Dr. Alsalaheen has over 10 years of clinical experience treating thousands of patients with concussion. His approach to physical therapy treatment of patients and athletes with concussion is multidimensional including interventions to target vestibular, cervical musculoskeletal, ocular-motor, and exertional impairments.

Dr. Alsalaheen is member of a small group of concussion experts currently in the final stages of development of the Clinical Practice Guidelines (CPG) for management of patients with concussion. Dr. Alsalaheen’ s educational background include a PhD in rehabilitation Sciences (University of Pittsburgh, US, 2013), Masters of Science in Physical Therapy (2008), and a Bachelor of Science in Physiotherapy (2006)

Course Description
One of the most popular paradigms of passive movement treatment in spinal dysfunction is the Maitland Concept and the corollary of this, Combined Movement Theory (CMT). The aims of this course are to introduce the fundamental similarities in approach between SMTT and CMT and introduce a process of SMTT selection based upon CMT. It is envisaged that adopting this rational of SMTT selection will provide the participant with a method of applying SMTT that integrates the two concepts.

Aims of the Course

• An Exploration of the Combined Movement Approach:
This course aims to provide participants with an opportunity to explore the treatment of spinal dysfunction using the Combined movement concept of treatment advocated by Dr Brian Edwards. This concept offers participants a rational way to select patient presentations suited to this method of treatment and a clinically reasonable way of incorporating manipulative thrust and end of range mobilization techniques into a passive movement treatment approach. The philosophy of the course is to facilitate the learning of participants by encouraging self directed exploration of the issues and avoidance of a didactic teaching style.
• Selection of Type and Position of Treatment:
This course does not set out to provide participants with a handful of manipulative thrust techniques rather encourages participants to develop skills in the selection of mobilisation and manipulation techniques in the appropriate clinical scenarios. An important tenant of this course is the emphasis on CMT being a component of a holistic approach to spinal dysfunction and not that this approach is the panacea to all spinal pain.
• The Development of Practical Handling Ability:
The course contains a large component of practical skill development however this element is grounded in the theoretical background of analytical assessment, validity of technique and risk /benefit. Before participants begin palpating the rational behind techniques are discussed.
• Development of Clinical Reasoning Skills:
Participants will know when, where and how to achieve the benefits of effective mobilisation and manipulation. More importantly they will know why they would consider this approach and what they should expect from it.

Learning Outcomes of the Course
On completion of the courses participants will be able to;

• Clinically reason what patient presentation type should be suited to the CMT approach.
• Have developed the skills to determine primary movement patterns suggesting source structures and corresponding starting positions for treatment.
• Developed skill in palpating the cervical spine anteriorly, and the thoracic spine posteriorly. The participant will be able to palpate muscle spasm and passive joint restriction.
• Clinically reason the decision of when to mobilise and when to manipulate a spinal joint. Appreciate the complexities of the issues surrounding pre-manipulative screening and the risk/benefits of end of range mobilisation and SMTT’s.
• Appreciate the evidence base behind mobilisation and manipulation in the treatment of spinal dysfunction.
• Clinically reason progression and regression of treatment and be conversant with the notation of treatment.

Thus, the courses strategies for learning include:

• Interactive lectures / group discussion
• Case scenarios – discussed in small groups
• Problem solving in small groups – debate on clinical decision making
• Practical sessions emphasizing continual feedback from participants and tutor.

Dr Christopher McCarthy is a Chartered Physiotherapist with an interest in Manual Therapy. He teaches combined movement theory and manipulation across the world for over 20 years. He is the former Chair of the MACP. His current research work involves an investigation into the clinical sub-classification of non-specific low back pain. He is one of the Editors of Grieve's Modern Musculoskeletal Physiotherapy and has a published textbook on this topic. Combined Movement Theory: A Rational Approach to Spinal Manipulation. (Elsevier 2010).