Concussion care management is all about having a well balanced team of health care professionals. Effective evaluation and management require a multidisciplinary team that can include physical therapists, occupational therapists, speech therapists, physicians, neuropsychologist, neuro-ophthalmologist, athletic trainers, teachers, and nurses. As our knowledge of what a concussion truly is advances, so does our care for concussions.
Common Concussion Myths
There are many misconceptions about concussions. With the wealth of information and advice available to us on the internet, it can be difficult to sort through all the material in order to figure out what is fact and what is fiction about management of concussion. Did you know there are currently 40 working definitions of what defines a concussion? Recently thanks to the NFL and other professional sports, the concussion discussion has become more mainstream in the news media. But with the rapid increase in interest, there has been unfortunately a lot of misinformation spread as well. Concussion injury does not just occur in sports, other head injuries can lead to this form of traumatic brain injury.
Let’s discuss a few common misconceptions about concussions and the true facts behind the myths.
- Myth #1– A concussion only occurs as a direct blow to the head.
- Fact– A concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body if the force of impact is transmitted to the head.
- Myth #2– All concussions, treatments, and recoveries are alike.
- Fact– Just as each person is unique, each concussive event is unique, and the recovery and treatment process differs greatly. No two concussions are the same. We can take two different people and give them the same head injury and they will respond differently. We could even take the same person and have them sustain two identical injuries and they will respond differently.
- Myth #3– You should be put in the dark room, avoid activity, avoid all screens, including TV and video games in order to recover.
- Fact– After a brief period of relative rest (24-48 hours) a gradual and progressive return to more physical activity should occur while staying below the symptom threshold.
- Myth #4 – You have to have loss of consciousness to have a concussion.
- Fact– You could suffer from a mild form a traumatic brain injury, with only mild symptoms from a blow or bump to the body or head.
What is a Concussion?
A type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.”
Concussion is a brain injury that occurs when the brain is violently shaken. The injury can happen during rapid movement changes (such as whiplash) or when the head is directly hit. This shaking or hitting of the head causes unpredictable injury to any area of the brain, resulting in immediate or delayed changes in the brain’s chemistry and function. Less than 10% of concussions involve a loss of consciousness. Depending on which area of the brain suffers injury, many different temporary or permanent problems with brain function can occur.
A concussion is an energy crisis of the brain. Directly after you sustain a concussion, there is a process called the neurometabolic cascade that happens in our brain. Think about it this way. In your mind, picture a petting zoo full of kids which represents your brain. There is a good balance of kids to animals in each area which is like the balance of chemicals in your brain. Then all of a sudden there is a massive clap of thunder (depolarization/action potential). The teachers blow a whistle (release neurotransmitter) and all the kids start running towards the gate (K+ efflux). The gate between the areas is now open and there are kids and animals running every which way (Na, K pump). The teachers try and get all the kids in the same area and need a lot of energy to do so (hyperglycolysis). The teachers are slowly running out of energy and can no longer direct the kids (decreased energy/ATP production) because of all the mud that is building up (lactate accumulation). The teachers try to gather all of the younger kids into one area (Ca sequestration) but this causes chaos with so many little kids in one small space and nothing to entertain them (mitochondria dysfunction). The teachers become exhausted, overrun by animals and kids, and can no longer corral all the kids (cell death).
How is a Concussion Diagnosed?
There is not one single test that can diagnose a concussion. A concussion is a clinical diagnosis, meaning it is based on the subjective history of the signs and symptoms taken from the patient, and on objective measurements taken by the health care professionals. Objective testing to assess the extent of the traumatic brain injury may include: cognitive, vestibular/balance, visual, musculoskeletal and speech tests. We will discuss some of these areas below that pertain to the physical therapists roll in concussion management. A CT scan or Magnetic Resonance Imaging (MRI) is rarely used for diagnosis. Only in some cases imaging is used rule out a more serious brain injury.
In case of an athletic injury, there are several on field tests that can be used to help the health care professional determine if a concussive event has occurred. These include the Standardized Assessment of Concussion, the Multidimensional Sport Concussion Assessment Tool, and the Military Acute Concussion Evaluation. The tests can be performed by a number of trained professionals including athletic trainers, coaches, physical therapists or a physician. The concussion evaluation can be rapidly performed with these tests. The evaluator checks for initial signs and symptoms such as loss of consciousness, head injury, headache, visual or hearing disturbances, nausea, etc. If the injury occurs at a sport event, it may be referred to as a sport-related concussion or concussion in sport. If the injury is a result of a car accident, work injury, or other trauma a person may not get a “concussion” diagnosis right away, but it may be referred to as mild brain injury, traumatic brain injury (TBI), whiplash sequela, or head injury.
Concussion Signs and Symptoms
UPMC Sports Medicine Concussion Program has developed six common trajectories, or types of concussions and their symptom profiles. Those six subtypes are: cognitive/fatigue, vestibular which is part of the body’s balance system, ocular or our vision, post-traumatic migraine which can also include nausea/vomiting and light or sound sensitivity, cervical or the neck and finally anxiety/mood. Rarely do these symptom subtypes occur in isolation, and often times people have symptoms from a number of these categories. The majority of symptoms tend to show up shortly after the injury, however it is not uncommon for new symptoms to develop later on.
Cognitive (Thinking) Concussion Symptoms
- Difficulty with short-term or long-term memory
- Slowed “processing” (a decreased ability to think through problems)
- “Fogginess”- can be characterized by slow reaction time, attenuated memory performance, slower processing speed
- Difficulty concentrating
- Worsening grades in school
Physical Concussion Symptoms
- Headache or Migraine
- Dizziness- this can be different for each person and can be described as spinning, lightheadedness, off balance
- Difficulty with balance and coordination
- Fatigue (cognitive and physical)
- Difficulty sleeping or increased sleepiness
- Double or blurred vision
- Sensitivity to light and sound
- Slurred speech
- Glassy-eyed stare
Emotional Concussion Symptoms
- More emotional
Sleep Symptoms of Concussion Injury
- Sleeping less than usual
- Sleeping more than usual
- Trouble falling asleep
- Trouble staying asleep
Red Flag Signs and Symptoms of Concussion
Red flag signs and symptoms, or those that would warrant an immediate trip to the Emergency Department are:
- One pupil larger than the other
- Drowsiness or inability to wake up
- A headache that gets worse and does not go away
- Slurred speech, weakness, numbness, or decreased coordination
- Repeated vomiting or nausea, convulsions or seizures (shaking or twitching)
- Unusual behavior, increased confusion, restlessness, or agitation
When Should I Go to Physical Therapy?
Many people who have experienced a concussive event will recover relatively quickly. Following concussion, a day or two of rest is recommended followed by a gradual resumption of low-risk activities. By definition post-concussive syndrome refers to symptoms such as headache, fatigue, dizziness, anxiety, depression and difficulty with concentration and exercise that exist beyond the “accepted time frame for recovery.”1 Berlin expert consensus on concussion refers to persistent symptoms as those lasted longer than 10 days to 14 days in adults and > 4 weeks in children.
For people who have ongoing symptoms after a concussive event, a physical therapist with expertise and training in this area of rehabilitation can help design a safe program for return to exercise, daily activities, sports, school and work. Comprehensive evaluation and management can be performed by a physical therapist that has been trained in concession management. The specialist performs tests for any mobility and movement impairments, assesses for trouble with vision or balance, and any other problems and symptoms you may have with day-to-day function or activities. What is found during this comprehensive exam will guide your treatment plan, which may also involve other health care professionals who can address specific findings. Referrals may be include occupational therapy, speech therapy, speciality physicians, neuropsychologist, neuro-ophthalmologist, or athletic trainers depending on the findings of the exam.
Concussion is a rehabilitative injury. Treatment can be done for each of the symptom subtypes with a targeted intervention. This includes both the physical symptoms of concussion such as headache and neck pain, as well as possible cognitive/fatigue symptoms.
According to the most recent consensus statement on concussion in sport: In the acute phase, the most important principles are to protect the patient from further injury (primarily by removal from play or high-risk activity), and to quickly evaluate the patient and rule out more serious injury, including cervical injury, skull fractures, and intracranial hemorrhage. The primary goals of post acute assessment are to provide appropriate management of the concussion, and to minimize the extent and duration of morbidity.
Vestibular Training and Treatment
According to research it has been found that approximately 60% of athletes have vestibular impairment and symptoms, such as dizziness, nausea, and imbalance, following sport-related concussion.2 These findings are similar to work done with non-athlete patients that found those with mild or moderate TBI with dizziness (66.7% of sample) were more anxious, had higher reports of depression, higher scores on outcomes identifying psychosocial dysfunction and were less likely to return to work. 3 According to other research, dizziness is the number one on field symptom predicting a protracted recovery. 4 Sub-acutely, it found that fogginess was the number one predictor of a protracted recovery.5 Both of these symptoms correlate with the vestibular system.
Our vestibular system is contained mostly within our inner ear and is made up of tiny organs that sense motion. Our body uses three different systems to assist with balance, our vision (eyes), proprioception (or our bodies ability to figure out where it is in space) and our vestibular system. The vestibular system is responsible for letting our brain know when we are moving. It sends information up to the brain in order to adjust for these movements. When we sustain a concussion, some of these pathways can be disrupted and the signals get crossed and we are not able to process movement of our head. This can cause dizziness, blurred vision and decreased balance.
While initial cognitive and physical rest is needed, it can be important to begin vestibular rehab even before all of these symptoms are gone at rest. If a person is dizzy even while at rest, and can not return to work or school after a few days to one week, it is important to start vestibular rehab treatment (when appropriate) because more rest will not help to retrain the vestibular system.
Oculomotor Training and Treatment
Vision is more than just our ability to see with 20/20 vision. That is just one way to measure how our eyes are functioning. We also have to consider how that information is being processed once we receive it. Did you know 70% of all sensory information that we receive comes in through our eyes? This means that how we process the world around us, largely depends on our vision.
Barnett et al remind us that visual dysfunction after mTBI can disrupt every aspect of vision including: acuity, accommodation, ductions, eye teaming, visual field, photosensitivity, color perception, contrast sensitivity, pupillary function, saccade production, visual memory, reading comprehension and visual recognition.
There are nine different areas of visual function that we can have difficulty when we can’t “see clearly.”
We can have a hard time with:
- recognizing objects.
- visually recalling something to our memory.
- the sense of balance being off.
- sensing motion around us or within our own body.
- the ability concentrate.
- judging interpersonal space.
- reading body language.
- understanding nonverbal communication and eye contact.
- slowed reaction time.
All of these factors go into our ability to “see clearly.” So while your “vision” may be 20/20 your eyes and brain may be having a hard time communicating and processing the information (images, motion and positioning) that your eyes are bringing in for your brain to process.
Exertion Training and Treatment
In 2016, the fifth International Conference on Concussion in Sport was held in Berlin, Germany. A consensus statement was published recommending that after an initial phase of 24-48 hours of relative cognitive and physical rest, a gradual return to sports/activity protocol should be initiated post concussion. The first step is daily activities that do not provoke symptoms. Once the patient is able to perform these daily activities without symptom increase for at least 24 hours, the next step of light aerobic exercise can begin6.
In a systematic review published in Feb 2017, it was found that the best available evidence from clinical studies does not support prescribing complete rest for more than a few days after suffering a sports related concussion.7 It has however been found that controlled exercise, performed at an intensity and duration that does not exacerbate symptoms, is both safe and beneficial for the patient.
Moderate aerobic exercise or 60% of maximum heart rate, is found to be cognitively protective, and is associated with greater levels of brain-derived neurotrophic factor (BDNF), which is involved in neuron repair after injury (3). Experimental animal data show that premature voluntary exercise within the first week after concussion may delay recovery and is associated with impaired cognitive memory task performance by interfering with the post concussion rise of neuroplasticity molecules including BDNF (3). Aerobic exercise performed 14 to 21 days after concussion, however, up-regulates BDNF in association with improved cognitive performance.8
Therefore, evidence in scientific literature for concussion indicates there needs to be proper management of activity both for physical and mental activities following concussion in order to achieve the best outcomes. Management of concussion symptoms can impact overall recovery and should be followed by medical professionals. Just going back to regular physical activity, sports, school, work, video games, screen time without evaluation may not be a wise choice following concussion for not only children and adolescents, but adults too.
Often times the cervical spine or neck is involved with a concussive event. Involvement may occur from a whiplash associated disorder, which is a sudden straightening and then rapid S curve movement of the neck, or it may occur from prolonged dizziness symptoms resulting in decreased cervical mobility. Cervical symptoms can compound headaches as well as dizziness and balance issues. 70% of headache sufferers complain of neck pain that goes along with their headache.
The cervical examination will include looking at symptom exacerbations (flair up) and relieving factors, active and passive range of motion, posture, strength testing and how the head and the eyes coordinate movement together.
As discussed earlier, our bodies use three different systems to assist with balance, vision (or our eyes) where 70% of our sensory information comes from, proprioception (or our bodies ability to figure out where it is in space, usually by our feet feeling the ground around us) and finally our vestibular system (or inner ear system). If any of these systems are not working properly, or working together, the result is a decreased sense of balance. The first step taken is to determine which system or systems is affected and causing the decreased balance. This can be done by performing several balancing tests which help to rule in and rule out the various systems that our body is using.
Return to Activity
In general, a graded return to activity guideline is followed. While you may not be a runner, you can probably imagine that running a full marathon (26.2 miles) is quite a feat. Well what would happen if you went from sitting on the couch the majority of the day to running a full marathon on the next day? Well, your body would not respond very well, and most likely you would cause further injury to your body. The same thing applies for your brain after a concussion. A concussion is a brain injury. If you did not give it the appropriate rest it needed after it was injured, but instead, trained it for the marathon, you may cause more harm than good. The more research that we do with concussions, the more we see that a paced graded exposure (training for the marathon ahead of time) is a better approach to recovery. Do not worry about trying to figure it out on your own. We have a certified concussion specialist at Red Rock Physical Therapy and Wellness to help guide the way. We understand management of concussion symptoms, and can help adults, athletes, children and adolescents get back to work, school, and sports.
When dealing with athletes, most schools have adapted their own return to play protocols but, they follow the same general concussion guidelines. In fact, all 50 states have enacted laws requiring an individual who is suspected of sustaining a concussion to be removed from play and evaluated by a medical provider before returning to play. In our area, the school districts require concussion baseline testing for all athletes starting in middle school to help with determining when an athlete is ready to play.
Each phase must be symptom free in order to progress to the next stage.
1) No activity- symptom limited physical and cognitive rest
2) Light aerobic exercise- walking, swimming or stationary bike keeping intensity <70% of max heart rate
3) Sport-specific exercise- no head impact activities
4) Non-contact training drills- progression to more complex sports drills, may start progressive resistance training
5) Full-contact practice- following medical clearance
6) Return to Play- normal game play
Similarly schools have a Return to Learn Protocol.
1) Daily activities at home that do not give the child symptoms; start with 5-15 mins at a time and gradually build
2) School activities- homework, reading or other cognitive activities outside of the classroom
3) Return to school part-time
The first question everyone always asks is, “How long until I am better?” When dealing with concussions this can be a difficult question to answer. The brain does not heal like other tissues in the body. It is important to remember that a concussion is a mild traumatic brain injury (mTBI). If you break a bone, you can be told with fairly good certainty that it will heal within 6-8 weeks. Our brains unfortunately do not work like that with a brain injury. Each person, each brain, each concussive event is different. As research continues to evolve, new studies are concluding that on average, the majority of concussion symptoms resolve within 3-4 weeks. This is compared to the 7-10 days that prior research had shown. However, it is known that up to 1/3 of individuals experiencing concussions do not recover in this time period.
Studies show that some pre-injury factors such as history of concussion, female sex, younger age, attention-deficit hyperactivity disorder (ADHD), history of migraine, and genetics may all be associated with prolonged recovery from concussion.
Another common issue that those suffering from concussion undergo is that, from the outside, the person usually looks fine. Concussion is often an invisible injury and more subtle sign and symptoms may not be obvious to the casual observer. It may be difficult for friends and family members to understand what is going on and why their loved one is unable to participate fully in their life, work, sports or school.
About Our Treatment
Here at Red Rock Physical Therapy we have a Certified Concussion Management Physical Therapist, Dr. Emily Rotert, PT, DPT. Our therapy specialist will perform a targeted comprehensive concussion examination to determine what areas need addressed for your case. This examination will include a through symptom check and past medical history, visual assessment, cognitive assessment, cervical examination, vestibular assessment as well as exertion testing if necessary. Upon evaluation, together with the patient, the therapist will determine the best course of action to get you back to the activities you love. Dr. Rotert can then communicate findings and treatment recommendations with your medical team, school, trainer and coach to help you achieve the best treatment outcome from your concussion injury.
Concussion Baseline Testing
We also perform baseline concussion testing which consists of balance, endurance, ROM and strength testing, cognitive/memory assessment and a vestibular and oculomotor exam. This data can be used for athletes in the case of a concussion and can help the therapist tailor a program for a successful return to play. Please give us a call or send us an email at firstname.lastname@example.org for further information.
The prevention of concussions can not be fully achieved, but there are things that can be done to minimize risk and reduce poor long term outcomes. Wearing of properly fitted helmets and mouth guards recommended for impact sports since they reduce the impact forces that contribute to head injury. Self reported concussions have increased with awareness and education about concussion and traumatic brain injury. 9 There is also research that is indicating that improvements in neck strength and reaction can also reduce forces on the head/neck at time of impact.10
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- Leddy JJ, Baker JG, Willer B. “Active rehabilitation of concussion and post-concussion syndrome.” Phys Med Rehabil Clin N AM 27 (2016) 437-454.
- Mucha, A et al. “A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings.” The American journal of sports medicine vol. 42,10 (2014): 2479-86. doi:10.1177/03635465145437752)
- Chamelian L, Feinstein A. “Outcome after mild to moderate traumatic brain injury: The role of dizziness.”Archives ofPhysical Medicine & Rehabilitation 2004;85:1662–1666.
- Lau et al. “Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players?” Clin JSport Med. 2011 Nov;39(11):2311-8.
- Lau et al. “Neurocognitive and symptom predictors of recovery in high school athletes.” J Sports Med 2009 May;19(3):216-21.
- McCrory P, et al. “Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016.”J Sports MMed 2017;0:1-10.
- Schneider KJ, et al. “Rest and treatment/rehabilitation following sport-related concussion: a systematic review.” J Sports Med 2017,51: 930-934.
- Leddy, et al. “Use of graded exercise testing in concussion and return-to-activity management.” Sports Med Rep, 2013; 12 (6), 370-376.
- Glang AE, Koester MC, Chesnutt JC, et al. The effectiveness of a web-based resource in improving post concussion management in high schools. J Adolesc Health. 2015;56(1):91–97.
- Eckner JT, Oh YK, Joshi MS, Richardson JK, Ashton-Miller JA. Effect of neck muscle strength and anticipatory cervical muscle activation on the kinematic response of the head to impulsive loads. Am J Sports Med. 2014;42(3):566–576.