Complete Concussion Management for Physical Therapists

Physical therapists play a key role in the concussion-related rehabilitation process.

Concussions, or mild traumatic brain injuries (TBIs), are a common sight in both private physical therapy clinics and hospitals. Proper and complete concussion management is crucial for optimal recovery. Physical therapists play a key role in the rehabilitation process. They not only work on relieving symptoms but also in restoring the patient’s full function.

This article outlines a guide to complete concussion management for physical therapists, helping them understand the epidemiology, pathophysiology, assessment, care, and rehabilitative strategies.

Recommended course: Tools for Concussion Assessment & Management

Epidemiology: Understanding concussions

Research is constantly evolving in terms of how to diagnose, evaluate, and treat concussions, forcing rehab professionals to constantly adapt to new treatment guidelines. This is a good thing. Concussions are a difficult injury to understand, and the medical approach to it is becoming increasingly beneficial to the patients.

Medical professionals define a concussion as a brain injury occurring due to sudden jolts or impacts to the brain, potentially causing temporary changes in function. The sheer number of annual concussions is astounding. The Centers for Disease Control and Prevention (CDC) estimate at least 1.5 million concussions happen in the USA every year. However, the number is likely much higher since many concussions go unreported, and about 90% of those concussions are mild cases.

The number of concussions is greater in males than females, with the most happening between the ages of 15-19. About 29% of all concussions involve a loss of consciousness, and certain sports tend to have the highest incidents, including:

• American football
• Hockey
• Lacrosse
• Soccer

These incidents are more frequent in-game settings than practices, suggesting that competitive sports have a higher incidence of concussions.

Concussion signs and symptoms

Concussions are a unique injury that present with different signs and symptoms based on the severity, type, and person.

• General symptoms: Headaches, cervical neck pain, dizziness, blurred vision, nausea, light/sound sensitivity, balance problems.
• Physical signs: Loss of consciousness, amnesia, neurologic deficits.
• Behavioral changes: Irritability, sadness, anxiety, depression.
• Cognitive deficits: Impaired memory, poor concentration, cognitive fatigue.
• Sleep problems: Difficulty falling asleep, drowsiness, excessive sleep, fragmented sleep.

Physical therapists need to perform a detailed examination, as the signs and symptoms of concussions vary greatly as shown above. Also, research suggests that a lack of symptoms does not rule out concussions when dealing with head impact injuries. It's important to be mindful of the buildup of damage that non-symptomatic concussions can cause if left untreated.

Diagnosing a concussion

Concussions cannot be diagnosed using standard MRIs or CT scans as there are no objective biomarkers. However, neuroimaging may be used to rule out hemorrhage, edema, or white matter changes when the injury does not improve.

Instability of the cervical spine sometimes causes a persistence in concussion symptoms, in which case imaging may be helpful.

Pathophysiology of concussions

A series of complex and disruptive events happen within the brain following a concussion, typically resulting in functional and clinical symptoms. While research is still actively attempting to understand the exact mechanisms, these are part of the events:

• Mechanical impact: A sudden impact or acceleration/deceleration force is what’s thought to begin the neurometabolic cascade of events. This is commonly due to a rapid head movement.
• Damage to brain tissue: The brain’s tissue temporarily compresses and stretches due to impact.
• Ionic shifts: The normal balance of ions in the brain (e.g. potassium and calcium) is disrupted, affecting the function of neurons. This interferes with normal cellular processes.
• Increased release of neurotransmitters: An abnormal release of neurotransmitters due to mechanical forces can lead to excessive excitation of neurons, contributing to concussion symptoms.
• Neuroinflammation: An inflammatory response may be initiated in the brain, causing further symptoms.

Physical therapy assessment of concussions

A Physical therapists must be mindful of the different symptoms (or lack of) that concussions may present and assess with utmost care. The main goal is to return the patient to regular activity and resolve symptoms, so the assessment needs to reflect these goals.

A thorough patient history is crucial for understanding the nature of the concussion and building a relationship with the patient. The rehab professional’s goal is to determine the initial and current symptoms, the cause of the concussion, and any risk factors.

This includes looking at:

• Previous medical issues: Existing medical conditions, prior concussions, disabilities, and head, neck, or face injuries.
• Social history: Extracurricular activities (e.g. sports), school/work environments.
• Current concussion: Mechanism of injury, initial symptoms, occurrence of loss of consciousness, seizure, or amnesia, and current triggers and symptoms.
• Initial care: When, how, and if the concussion was officially diagnosed.
• Current medication: What prescribed/unprescribed medication is being/was taken.
• Severe symptoms: Transient, sudden, or severe symptoms may require immediate referral to a physician or emergency care.

Depending on the history, the physical therapist may opt for different tests that could rule-in or rule-out a concussion.

• Vestibulo-ocular system issues
• Cervicogenic system issues