Discussing the role PT plays in concussion management and prevention

1. 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

2. 2
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

3. 3
SELECT PT SUMMER 2015
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.

4. 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
SELECT PT SUMMER 2015