PT Classroom - The Role of the Physical Therapist When Working With Patients With Post-Concussive Syndrome (Part 1)  ׀ by Lauren Hogan, PT, DPT, ATC

Concussions (or mild traumatic brain injuries) have received considerable press due to the high prevalence in sport and the potential for long-term and often disabling symptoms. A concussion may occur when there is a direct impact either to the head or with a blow elsewhere in the body with forces that are transmitted to the head. The acute symptoms of a concussion are generally not the result of pathological or structural changes, and thus no abnormalities are seen on radiographs or other imaging (4). Instead, symptoms are due to microscopic axonal injury and a resultant “neurometabolic cascade” occurring within the brain (3). The normal ionic balance and energy metabolism are disrupted and the brain then requires increased energy to return to its normal state. Unfortunately, there is decreased cerebral blood flow and mitochondrial dysfunction post-injury, so less glucose is available in the brain (3). This energy supply-and-demand mismatch can cause concussion symptoms.

Concussion symptoms vary based on the patient and a list of common symptoms is found in the box below. Headaches are the most frequently reported symptom, followed by dizziness (3). The vast majority of concussions will resolve quickly, with 80-90% of patients experiencing symptom resolution after seven days (3). There is some concern that cognitive deficits may persist even after symptom resolution, which has been shown with neurophysiological testing. Further research continues to be done in this area to assure full resolution of symptoms prior to return to activity (3).

Following a concussion, patients are prescribed rest from physically and cognitively fatiguing activities to allow the brain to recover (4). In addition to resting from sports, patients are often held out of full school or work days and have other restrictions, including no taking notes, reading or testing, nor use of computers, cell phones or television. They may also be encouraged to avoid bright or noisy environments. Excessive activity, either physical or cognitive, increased the energy demand upon the brain and may lead to prolonged symptoms. Patients are also cautioned against the return to any activities that have the potential to cause further trauma to the brain. Until the brain fully recovers from the initial injury, it is more vulnerable to re-injury. The second injury is usually more severe, and in the case of second-impact syndrome, may lead to permanent deficits or even sudden death (2). Recurrent injuries may lead to long term cognitive deficits, as in chronic traumatic encephalopathy (CTE), though further research needs to be done to determine if there is a true cause-and-effect (4).

Prior to participating in contact sports, athletes should undergo preseason baseline concussion testing (2). These may include tests like the SCAT-3, NFL Sideline Concussion Assesment Tool, or the computerized ImPACT testing, as well as a balance test, such as the Balance Error Scoring System (BESS) Test. Tests are repeated following a suspected concussion and pre- and post-injury scores are compared. This allows health care professionals to compare pre- and post-injury status for the presence of concussion and later for return-to-play decisions (2). Copies of concussion assessment tools are below:

· SCAT 3
· NFL Sideline Concussion Tool
· BESS Test

Patients should be held from physical activity until they return to their pre-injury status to prevent the risk of a catastrophic event. Once a patient is deemed to be symptom-free by a physician, athletic trainer or physical therapist or other health care provider, they may begin a gradual return to activity. With a typical concussion that resolves quickly, the patient may progress through the return to play (RTP) protocol with one day at each stage, pending no increase in symptoms during or after (4). An athletic trainer or physical therapist is often helpful in safely progressing through the RTP protocol. If any concussion symptoms increase, the patient needs to rest until symptoms resolve, then take a step back and repeat the previous stage before continuing the RTP protocol (3). Patients who experienced persistent or severe post-concussive symptoms are often progressed more slowly, spending multiple days at each level. Patients with a history of previous concussions or those with more complex recoveries will likely require physician release for return to contact activity.
 

Approximately 10-15% of those sustaining a concussion will still experience symptoms after ten days (3). Risk factors for persistent symptoms include (2):
- History of previous concussion(s)
- Greater number of symptoms or increased severity of initial symptoms
- Female gender
   o May be due to the relationship between estrogen & cerebral blood flow or

      due to decrease head-neck mass
- Younger age
   o Due to lack of development of the brain
- History of depression, anxiety, irritability, learning disabilities, ADD/ADHD
- History of migraines or other headaches

Typically, a physician and/or an athletic trainer manage concussions, though patients with long-lasting concussive symptoms may benefit from referral to other health care professionals. Physical therapists may assist with physical symptoms, while a neuropsychologist is able to assess and treat cognitive and emotional symptoms that persist.

Physical therapists can play a vital role in the treatment of post-concussive syndrome and are often under-utilized. Physical symptoms may persist weeks after the initial injury and severely impact daily function. Headaches due to head trauma may have a cervicogenic component, much like whiplash. Addressing cervicothoracic mobility and soft tissue restrictions can often provide relief. In addition, strengthening deep cervical flexors and scapular stabilizers can also assist in improved scapulothoracic and cervical stability and decrease in headaches.

In addition, patients with post-concussive syndrome may have persistent dizziness, blurry vision, or balance deficits that may benefit from physical therapy (1). They may note difficulty walking through the hallway at school, riding in a car, with a change in head position, reading, or taking notes in class. A physical therapist experienced in vestibular rehabilitation can provide exercises to address ocular mobility, gait, and balance to allow for improved daily function (1).

Given the complexity of concussions and the variability of recovery, patients will often benefit from a team of health care providers to allow for the most efficient and thorough recovery. This team may include the physician, athletic trainer, physical therapist and neuropsychologist, in addition to the athlete, and possibly family. Though knowledge about concussions has increased dramatically in the recent past, continued research needs to be done. In addition to determining the most appropriate way to identify and treat an individual suffering symptoms from a concussion, we need to further our knowledge in preventing these injuries.

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