concussion and physical therapy

Concussions + Treatment

S E L E C T P H Y S I C A L T H E R A P Y

Overview Concussions, which can result in mild traumatic brain injuries (mTBI), have become a growing concern in the medical community due to an increase in prevalence and in the need for research surrounding them.

Young athletes are the most common population to be affected by concussions and are often evaluated with screening tools after the incident. Common screening tools include the Standardized Assessment of Concussion (SAC), Sport Concussion Assessment Tool (SCAT) and Balance Error Scoring System (BESS). (1)

Symptoms of concussion can begin immediately after injury or may show up in the following weeks. Including depression, dizziness, drowsiness, fatigue, headache, irritability, loss of consciousness, memory issues, nausea, poor balance, ringing in the ears, and sensitivity to light or sound. (2)

The most common treatment of concussion calls for mental and physical rest for 1 to 2 days, however research has found that longer bouts of inactivity like 5 days, did not equal a faster return to function. (3) The fear of young athletes identifying a concussion after an injury and being taken out of the game still remains a roadblock to diagnosis and treatment. (1) Often, a patient does not get referred to physical therapy until the symptoms have persisted for more than 2 weeks, by this time the condition is considered post-concussion syndrome.

A brief guide to concussion

symptoms + treatments

Jill Stephenson CU DPT student | Class of 2016D

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SELECT PT SUMMER 2015

Following a concussion, patients can exhibit many symptoms of whiplash. Including tenderness and spasm in the cervical muscles and sometimes a mild subluxation of the atlanto-occipital joint as a result of impact, which can cause symptoms of dizziness and nausea to linger without resolving. Using manual therapy techniques and soft tissue mobilizations can correct this. Those presenting without neck pain or limited range of motion will most likely not benefit from such treatment.

Manual Therapy Techniques (4) In the study by Burns, two manual techniques were used. First, a lateral glide rotation at the atlanto-

axial joint was performed by locating both transverse processes of C1, determining symmetry, stabilizing the dysfunctional side and instructing the patient to rotate towards the side of dysfunction and to hold for 15 seconds. Second, while traction was performed by therapist, the patient was instructed to actively contract lateral musculature, the side with less range was then stretched manually to encourage cranium and C1 realignment.

Soft Tissue Mobilizations (4) Burns also focused on myofacial release of the scalenes, sternocleidomastoid, levator scapula, and

suboccipital muscles.

Results (4)

After two treatments of 45 minutes, the patient reported improvement in all pre-treatment symptoms. The patient was able to reinitiate schoolwork and return to sport gradually with no symptoms.

Where PT Comes In Whiplash

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Vestibular + Balance Rehabilitation (5) Vestibular therapy would be indicated for those with post concussion syndrome that have not had improvements in dizziness or nausea. Specialized maneuvers for benign paroxysmal positional vertigo (BPPV) like the Canalith repositioning maneuver can be performed by therapists with vestibular education. Balance or gait deviations can be addressed by all therapist through static balance exercises with a changing base of support and altered visual input. Dynamic balance exercises are more challenging for the patient, including walking with head turns and completing cognitive or physical tasks during ambulation. This type of therapy is focused on addressing the movements and activities that reproduce the patient’s symptoms, which can lead to aggravation of symptoms during therapy.

Education (6) Education about the process of concussions, the proper way to return to sport and activities, and the cumulative nature of concussions should be address with the patient. Education is especially important for young athletes eager to return to sport to improve compliance and avoid reinjury. Addressing that retuning to sport will be a slow process, beginning with being symptom free then progressing from light aerobic activity to noncontact drills to game play.

Aerobic Exercise For those patients that are slower to recover, light aerobic exercise has been shown to help progress their recovery. The concept being that light aerobic exercise will increase cerebral blood flow.(7) Subjects must be asymptomatic prior to beginning a bout of exercise.(8) Exercise at 50-60% of maximal capacity was continued for 15 minutes or until symptoms increased.(8) Subjects performed coordination exercises as well as sports related visualization.(8) Towards the end of therapy sessions, subjects were instructed on a home exercise program to continue aerobic and coordination exercises related to their sport at home.(8) If subject was asymptomatic at the same workload for one week, return to activity protocol was followed. (8)

Conclusion Despite the prevalence of concussions, research is still far behind where it needs to be. With the link between multiple concussions and degenerative brain diseases, research for concussions has ramped up but is still in its infancy. As more research is done, we can become more effective with our treatments for post concussion syndrome and better understand how to help with the knowledge we have.

Citations 1. Committee on Sports-Related Concussions in Youth; Board on Children, Youth, and

Families; Institute of Medicine; National Research Council; Graham R, Rivara FP, Ford MA, et al., editors. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington (DC): National Academies Press (US); 2014 Feb 4. 3, Concussion Recognition, Diagnosis, and Acute Management. Available from: http://www.ncbi.nlm.nih.gov/books/NBK185340/

2. Cantu RC, Aubry M, Dvorak J, Graf-Baumann T, Johnston K, Kelly J, Lovell M, McCrory P, Meeuwisse W, Schamasch P, Kevin M, Bruce SL, Ferrara MS, Kelly JP, McCrea M, Putukian M, McLeod TC. Overview of concussion consensus statements since 2000. Neurosurg Focus. 2006 Oct 15;21(4):E3. PubMed PMID: 17112193. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17112193

3. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015 Feb;135(2):213-23. doi: 10.1542/peds.2014-0966. Epub 2015 Jan 5. PubMed PMID: 25560444. Avialable from: http://www.ncbi.nlm.nih.gov/pubmed/25560444

4. Burns SL. Concussion Treatment Using Massage Techniques: a Case Study. International Journal of Therapeutic Massage & Bodywork. 2015;8(2):12-17. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455610/

5. Aligene K, Lin E. Vestibular and balance treatment of the concussed athlete. NeuroRehabilitation. 2013;32(3):543-‐53. doi: 10.3233/NRE-‐130876. Review. PubMed PMID: 23648608. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23648608

6. d'Hemecourt P. Subacute symptoms of sports-related concussion: outpatient management and return to play. Clin Sports Med. 2011 Jan;30(1):63-72, viii. doi: 10.1016/j.csm.2010.08.008. Review. PubMed PMID: 21074082. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21074082

7. Leddy JJ, Cox JL, Baker JG, Wack DS, Pendergast DR, Zivadinov R, Willer B. Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. J Head Trauma Rehabil. 2013 Jul-‐Aug;28(4):241-‐9. doi: 10.1097/HTR.0b013e31826da964. PubMed PMID: 23249769. Avialible from: http://www.ncbi.nlm.nih.gov/pubmed/23249769

8. Gagnon I, Grilli L, Friedman D, Iverson GL. A pilot study of active rehabilitation for adolescents who are slow to recover from sport-‐related concussion. Scand J Med Sci Sports. 2015 Mar 3. doi: 10.1111/sms.12441. [Epub ahead of print] PubMed PMID: 25735821. Avialble from: http://www.ncbi.nlm.nih.gov/pubmed/25735821


concussion and physical therapy

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