Last week, I took you through a very thorough way to evaluate and differentially diagnose an athlete with concussion. I used myself as an example, and also gave a little case study:
Sixteen year old female soccer player comes to your clinic with a primary complaint of medial knee pain following a collision with another teammate during soccer practice one week ago. Past medical history is significant for migraines. In the past week, she has also been experiencing dizziness, fatigue, mood swings, difficulty concentrating, sensitivity to light, and intolerance of loud noises. she has had difficulty reading things close up.
We talked a little about how symptoms of concussion can mirror symptoms of migraines, and the importance of differentially diagnosing the two. Suppose your examination, evaluation, and differential diagnosis lead you to believe that this is a case of concussion. How would you treat? Can you even? Or do you need to refer to a physician?
I would argue that physical therapists are EXTREMELY well-equipped to treat concussion! Of course, you would absolutely want to notify the athlete’s team physician, primary care physician, coach, and athletic training staff etc, so that they can follow up with you about any changes and help reinforce your education.
Patients who would benefit from skilled physical therapy intervention usually complain of:
-Dizziness and/or vertigo
-Other physical complaints following concussion injury
-lack of confidence concerning safe return to play
Concussion treatment will most likely include education, rest, and physical rehabilitation.
I’ve heard from several of the faculty at Duke that the more time you spend as a clinician, the more time you spend educating your patients. Education is extremely important in concussion, because the main treatment is REST.
Most sports physical therapists, the good ones at least, don’t like to tell their athletes to rest. Athletes hate it – I mean, wouldn’t you hate it if someone told you not to do your favorite activity, or not to go to work? You’d probably get pissed and defiant and do it anyway. Most of the time, keeping athletes as active and involved as possible is a good way to treat. NOT SO with concussion. This is one case where you ABSOLUTELY DO NOT WANT THE ATHLETE TO PARTICIPATE IN GAMES, PRACTICE, OR ANY HIGH INTENSITY ACTIVITY.
The main reason for this is the risk of second impact syndrome. If the brain sustains a second concussion before the first has healed, it’s protective reaction is to swell. Swelling = compression of the brain inside the skull, which can lead to severe damage; ie a traumatic brain injury that will more often than not permanently and dramatically alter the athlete’s brain – personality, cognitive function, physical function, memory, vision, hearing, you name it. If not treated quickly enough, the brain could swell so much that it starts pushing through the foramen magnum of the skull into the brainstem. Compression to the brainstem=instant death.
Have I scared you yet? DO NOT ALLOW ATHLETES TO PRACTICE OR PLAY OR ENGAGE IN HIGH-IMPACT ACTIVITY UNTIL THEIR CONCUSSION HAS HEALED.
While you don’t want to scare your athletes, you DO want them to understand the severe implications of second impact syndrome. Find a way to educate them without leaving them terrified of ever playing again – assure them that they simply need to wait for the green light, and in order to reach that point, they need to first rest, and then slowly build back up.
There are two aspects to the resting phase of concussion that mirror the two participation deficits most concussion patients experience: physical rest and cognitive rest. This period should last about 1-2 weeks at which point, if the patient is still experiencing symptoms without relief, physical therapy intervention should begin.
-Complete physical rest for up to three days following the injury
-After 3 days following the injury, light cardiovascular exercise such as walking and the recumbant or stationary bicycle are advised (blood flow to the brain is a good thing yall!)
-After two weeks, the patient may GRADUALLY begin amping up the intensity of their cardiovascular exercise and begin to incorporate weight training – provided they are symptom-free (see below).
-Limit exposure to bright lights, loud noises, and highly stimulating environments
-Limit screen time
-Limit reading, if this provokes symptoms
-Decrease stress levels
THe theory behind cognitive rest is that, following concussion (it’s a mild traumatic brain injury, after all!), the brain goes into a “neurometabolic crisis” mode, where it uses more energy than normal to heal- thus, it has less energy available for processing excess stimuli and stress and as such, stimuli and stress will provoke symptoms.
Following an initial rest period, once symptoms begin to subside, the athlete can gradually return-to-play and return-to-learn
Return – to -Learn Considerations:
Here, the athlete should gradually reintroduce homework and school work. Homework can be reintroduced for up to fifteen minutes of concentration at a time; regular breaks should follow. If symptoms are stable, the athlete can increase concentration on schoolwork by 5-10 minutes per day; so, 20-25 minutes of homework at a time; 30 minutes the next day; 35 the next, until the athlete can tolerate at least one hour of homework at home. Once they can tolerate 1-2 hours of homework, the athletecan return to class. It’s best to take it in half days at first, and if symptoms are stable, progress to full days.
As stated above, after two weeks of rest and light aerobic activity, the athlete may begin increasing the intensity of their exercise. It might be a good idea to perform a cardiovascular stress test on your athlete to determine how hard they can push themselves. As the athlete improves and so long as symptoms are stable, they can then progress to resistance training, then sport-specific drills, then practice, and finally, once cleared by a physician, they can return to play.
Other Rehab Considerations:
Aside from education on rest and progression, you will simply treat the impairments that your client complains of – balance issues, vertigo, and cervical spine pain. Some considerations for your interventions:
-Start slow! do NOT provoke symptoms!
-Starting in a calm, quiet, non-stimulating environment is best. As symptoms improve, you can change the environment to challenge the patient but if it provokes symptoms, it will only set you back.
-REFER if you need to: (complaints of “worst headache of my life”, chronic headache or migraine symptoms that are not already being medically managed, positive cranial nerve exam findings, central vestibular findings, cervical spine instability or suspicion of a fracture, quickly deteriorating cognitive or physical function)
Hopefully, this series will help you effectively manage the concussed athlete – whether you are the provider on the sidelines, or are providing direct access care for an athlete that has a suspected concussion or is even just at risk for one!
Special thanks to Dr. Jeff Hoder, PT, DPT, NCS and Dr. Corinna Martinez, PT, DPT, SCS, LAT, ATC, for teaching concussion management at Duke DPT 🙂
Leddy et al 2016. The role of controlled exercise in concussion management. Physical Medicine and Rehabilitation 8(3): S91-S100.
Leddy and Willer 2013. Use of graded exercise testing in concussion and return-to-activity management. Current Sports Medicine Reports 12(6): 370-376