PT Classroom - The Role of the Physical Therapist When Working With Patients With Post-Concussive Syndrome (Part 2)  ׀ by Lauren Hogan, PT, DPT, ATC

The vast majority of concussion symptoms will resolve quickly with proper treatment. Approximately 80-90% of patients experience improvement in symptoms in 7-10 days after injury. Unfortunately, 1-5% of patients with concussions will still be symptomatic after one month (5). Physical therapists can play a vital role in the treatment of post-concussive syndrome (PCS), especially for those patients experiencing persistent or severe headaches, dizziness, and balance impairments.

Between 23-81% of people will experience dizziness, or altered balance and coordination after a concussion (1). In most cases, these symptoms will improve with rest, though a subset of patients with prolonged symptoms may benefit from vestibular physical therapy. Patients may not explicitly report “dizziness” and may describe their symptoms using other terms including:
- feeling off balance
- vertigo
- light headedness or fogginess
- spinning of either self or environment
- nausea
- sensation of motion (1)

The vestibular system, including the inner ear and its connections to the brain, is responsible for stabilizing visual images on the retina during head movement, maintaining postural stability, and provides information for spatial orientation (6). As a result, vestibular dysfunction can significantly impair a patient’s ability to function in daily life and return to school, work, athletics, and other activities.

Initially, a physical therapist needs to determine the cause of symptoms. Vestibular symptoms following a concussion may be due to a myriad of causes such as:
- inner ear disorders - benign paroxysmal positional vertigo (BPPV), labyrinthine concussion, perilymphatic fistula
- central nervous system dysfunction - post-traumatic migraine, brainstem concussion, autonomic dysregulation/postural hypotension, oculomotor abnormalities, seizures
- musculoskeletal disorders - cervicogenic dizziness (8)

A thorough neurological examination is warranted, including assessment of cranial nerves, myotomes, dermatomes, muscle stretch/deep tendon reflexes and other tests to rule out other more severe neurological involvement, such as Hoffman’s, Babinski, rapid alternating movements, and clonus. Patients often demonstrate postural instability with balance tests such as the Sensory Organization Test (SOT), Clinical Test for Sensory Interaction in Balance (CT-SIB), the Balance Error Scoring System (BESS), Dynamic Gait Index, or Functional Gait Assessment. Physical therapists or other health care providers may utilize tests such as the Dix-Hallpike and Horizontal Roll Tests to assess the semi-circular canals for the presence of BPPV and treat appropriately.

In addition, a vision assessment should be done. The eyes provide visual input to the brain and vestibular systems to allow for maintenance of balance and postural stability. Following a concussion, patients often have difficulty with gaze stabilization, leading to feelings of dizziness with movements of the eyes or the head. They will often report dizziness with reading, taking notes from the board in class, or walking through hallways or store aisles. A patient with a concussion may demonstrate spontaneous or gaze-evoked nystagmus, or have difficulty or reproduction of symptoms with the vestibulo-ocular reflex (VOR) smooth pursuit and saccadic eye movements.

Other than with treatment for BPPV, the goal of vestibular rehabilitation is to facilitate central nervous compensation, rather than truly altering the vestibular system (3). Literature regarding vestibular rehabilitation specifically following concussion is currently sparse, but is gradually increasing with the growing concern and interest in the treatment of PCS. Alsalaheen et al. reported improvement in gait and balance with vestibulo-ocular reflex (VOR-1) exercises and balance training in patients with persistent symptoms following a concussion (1). VOR exercises generally begin with fixing eyes on a stationary target on a blank background and shaking head left and right or up and down while keeping the target focused. Patients often fatigue quickly and may have an increase in symptoms if progressed too quickly, so speed, duration and frequency are slowly increased up to 1-2 minutes, performed 2-5 times per day. As patient improves, the exercise may be progressed with a more distracting background, such as a checkerboard, or with dynamic activities such as walking (7). Patients may also benefit from smooth pursuit or saccadic exercises. Balance can be challenged with decreasing base of support, progressing to a softer surface or with eyes closed, and moving from static to dynamic activities. Patient demonstrating difficulty with convergence-divergence of the eyes may initially have difficulty with tossing and catching a ball, which can be used as an exercise. As a patient improves, physical therapists can get creative with vestibular and gaze stabilization exercises, involving more dynamic activities that can ease return to sport, such as core rotations or cone touches with reach with varying points of focus.

Persistent headaches are the most commonly reported symptom of post-concussive syndrome (8). Patients may have symptoms consistent with cervicogenic headaches, migraine, combined migraine and cervicogenic headaches, or secondary to cognitive fatigue. Currently, literature specifically tailored to the treatment of post-concussion related headaches is lacking, so it is suggested that management is based on primary headache categories and treatment (8). Physical therapists should do a thorough subjective and objective examination to determine the source of headache symptoms. Given the trauma often present with a concussion, patients may demonstrate symptoms consistent with whiplash and associated disorders (WAD) that may cause cervicogenic headaches. Physical therapists should address range of motion, cervicothoracic mobility, scapular stabilizer and deep neck flexor strength and endurance, and for the presence of muscular dysfunction and trigger points. Cervical mobility, pain, and function often needs to be addressed before a patient is able to progress with VOR exercises.

Immediately following a concussion, there is a period of physical and cognitive rest to allow for the brain to return to homeostasis. Exercise too soon after injury may prolong recovery (4). Once a patient is symptom-free at rest, the five-step return to activity protocol may begin. For patients experiencing persistent symptoms at three weeks or more, initial exercise assessment and gradually increasing aerobic exercise at a subsymptomatic threshold may assist with recovery (2). More research needs to be done, though early studies are promising.

With the frequency of concussions and the potential for long-lasting symptoms, research continues to be needed regarding the treatment of PCS. Early studies do indicate that patients with persistent symptoms may benefit from physical therapy and current concussion management recommendations reflect this. As a result, proper and timely referral to physical therapists experienced with rehabilitation of PCS may assist with improvement of symptoms and return to daily function.