Concussions have become more and more popular in the research community as of late, partly due to their higher incidence in sports and recent media recognition. According to the Brain Injury Research Institute, it is estimated that about 1.6-3.8 million sports and recreational concussions occur each year. That is an astounding number considering those are only sports and recreational injuries and do not include concussions due to falls, motor vehicle collisions, bumping the head off of an object, etc. With this recent increase in research, the condition is now more recognizable and treatable than it has been in the past.
Concussions have recently been classified as a mild traumatic brain injury due to the nature and seriousness of the condition. According to the American Academy of Neurosurgeons, a concussion is defined as,” A clinical syndrome characterized by immediate and transient alteration in brain function, including alteration in mental status and level of consciousness, resulting from mechanical force or trauma.” The brain functions as the command center for the rest of the body, and when it is not functioning properly the whole body suffers.
Mechanism of Injury
Concussions can occur in a variety of ways and do not require a direct blow to the head. Other acts that can cause concussions include whiplash from a motor vehicle collision, falls, or a blow to the body during a sporting event. This is surprising to many people, but is a very important concept to remember. Concussions can often go undiagnosed because many people believe that a direct blow to the head is required to cause the injury and do not seek medical attention.
When the injury occurs, brain matter is stretched in a way that the tissue is not designed to tolerate. This stretching causes ion channels to open within the brain matter causing a disruption in the brains “happy state” or homeostasis. Proper ion flow dictates cell signaling and functioning within the brain. When homeostasis is interrupted, it can cause the brain to function improperly affecting memory, consciousness, ability to concentrate, balance, vestibular function, and autonomic regulation of various systems. Symptoms begin to manifest because of this “malfunction” in the brains ability to carry out its regular processes.
Symptoms of Concussion
Symptoms can vary significantly from individual to individual. Some of the most common symptoms are listed below:
- Neck pain
- Sensitivity to light, sound, motion
- Altered personality
- Loss of consciousness
- Memory deficits
Rest following a concussion is extremely important. This is often the first thing that is “prescribed” following a concussion. Due to the disruption of ion levels in the brain tissue, the body must work extremely hard to restore proper resting levels. In order to heal and restore this ion balance, the body must devote a large amount of fuel (generally carbohydrates) to the brain. This is why patients generally feel fatigued and drowsy following a concussion. The brain is usually able to heal and restore homeostasis quickly (5-14 days), but if rest is not held as a priority detrimental effects to the healing process can occur.
Rest following a concussion is multifaceted. It is required that not only the body be rested, but the mind as well. Resting the body is generally self-explanatory, but resting the mind can be more vague. Resting the mind includes avoidance of taxing activities including work, school, busy environments (supermarket or sporting events), driving, TV, computer and cell phone use, some social situations, and generally anything else that may provoke symptoms.
Generally, concussive symptoms resolve and the brain is healed within 2 weeks. On the other hand, every concussive case is different and healing times can vary greatly based on age, general health, and adherence to the rest protocol. Occasionally it can take months for symptoms to fully begin resolving. When symptoms last beyond the normal healing time of 1-2 weeks, it is termed post-concussive syndrome. This condition consists of a collection of signs and symptoms similar to those experienced following the initial injury. Lasting symptoms may need further evaluation and treatment to completely resolve.
Physical Therapy Diagnosis- Initial evaluation
Physical therapists are trained in the evaluation and diagnosis of concussion. The initial evaluation generally consists of an interview and physical examination. The interview is used to gain valuable information about how the condition began and what symptoms are present, as well as a baseline level to look back on following treatment. The physical examination generally consists of a cervical spine evaluation and a variety of tests/measures to assess the function of the cognitive, balance, vestibular, and other physiologic systems. If the diagnosis of concussion is made, counseling on rest, safe return to school, work, or activity will be completed and the patient will follow-up when symptoms have subsided or within 2 weeks.
Physical Therapy Treatment
When symptoms last longer than anticipated, physical therapy intervention may be indicated. Following examination to obtain baseline levels, the physical therapist will develop a treatment program to specifically target the systems that have been affected by the condition. Generally, treatment will consist of determining a safe level of exercise for each patient as well as interventions to target specific deficits that may manifest following a concussion. The following sections will describe some of the bodys systems that may be affected.
The Vestibular System
The vestibular system is one of the balance systems and is located within the inner-ear. It assists in orientating the head relative to body position and stabilizing the eyes gaze on objects. This is important for many tasks including walking and driving. If the vestibular system is malfunctioning, patients generally experience dizziness, nausea, vomiting, vertigo, and inability to concentrate. Physical therapy can help the system recover from dysfunction through the use of vestibular rehabilitation exercises. The rehabilitation plan can focus on strengthening the system, habituating the system to certain movements, or compensating for a loss in system function through the use of visual or somatosensory information.
The Balance System
The balance system consists of three subsystems including the vestibular, visual, and somatosensory systems along with the connecting structures including the cerebellum and different areas of the brain itself. Following a concussion, the brain may have trouble processing the information from these different systems, leading to feelings of unsteadiness. Through physical therapy, the brain can be trained to respond appropriately to the information from the periphery or use compensatory strategies in order to increase or decrease the response to specific subsystems.
Physiological Response to Exercise
The BCTT can be used to assess whether or not the brain has physiologically healed. It is also an excellent way to develop a proper intensity of exercising that will be safe and promote brain healing. The physical therapist will be able to use this test to prescribe an appropriate amount of exercise, tailored to the individual to get them back to activities they love to do.
Call to Action
If you know anyone who has recently sustained a concussion or anyone who may have sustained an injury some time ago but continues to present with post-concussive symptoms, have them call or visit the clinic so that we can choose the best course of action. Remember, early intervention generally leads to better outcomes in the end!
Please see BLANK section and see the attached articles for review to help you understand the research behind the injury itself as well as the different treatment approaches for the different systems that may be affected.
Written by Bryan Esherick PT, DPT, physical therapist at Balanced Chiropractic and Physical Therapy
What is a Concussion? What is a Concussion? | Brain Injury Research Institute. http://www.protectthebrain.org/Brain-Injury-Research/What-is-a-Concussion-.aspx. Accessed February 15, 2017.
The American Association of Neurological Surgeons. Concussion. http://www.aans.org/patient%20information/conditions%20and%20treatments/concussion.aspx. Accessed February 15, 2017.