What Is Concussion?
Concussion is the most common brain injury and is caused by rapid movement changes such as whiplash or sudden direct blow/bump to the head or. The shaking and twisting of the soft brain tissue inside the skull can cause damage to the tissue of the brain, blood vessels, and injury to the nerves. This might result in malfunction of the brain for short or longer periods of time. Traumatic injury to the brain can result in immediate or delayed changes in the brain’s chemistry and function. Some symptoms are disturbance in vision, loss of equilibrium, and in less than 10% of cases unconsciousness.
A variety of temporary or permanent symptoms might occur depending on which area of the brain is affected.
Concussion occurrence (indirect or direct blow to the head) happens due to: sports injury to the head or neck, motor vehicle accidents (e.g. whiplash, head trauma), work place accidents, falls (the leading cause of concussions), and etc.
Concussion might accompany other injuries to the neck and shoulders that need to be treated by a licenced physiotherapist. Recovery from symptoms might take from 2 weeks to several months or years depending on the age of the patient and also the severity of the injury to the brain tissue. A symptom that persists two months after the initial concussion injury is called post-concussion syndrome. It is important to avoid intense physical activity right after injury and seek medical attention immediately after head injury. Proper and immediate medical attention can reduce the risk of death and permanent brain damage.
It is essential for people with recent concussion to stay away from sport activities and also take precautions to prevent a second concussion. The second impact has been shown to cause permanent brain damage and in some cases death. A physical therapist will work to develop safe guidelines for return to play, return to work, and return to life’s daily activities. Athletes or kids who have a concussion incident should be immediately removed from the play and stay away for a period of time advised by the physician or a physiotherapist. People with history of concussion often need more recovery time.
Signs and Symptoms
Symptoms related to concussion can be physical, cognitive and emotional. Symptoms can occur immediately, within a few hours to months or years after injury. Symptoms can be short or long term which can appear months after concussion. Some symptoms might be lasting more than expected. These symptoms require further examination and treatment in a multi-disciplinary setting including a physiotherapist.
Physical short-term symptoms include:
Headache, dizziness, difficulty with balance and coordination, nausea/vomiting, fatigue, difficulty sleeping, increased sleepiness, double or blurred vision, sensitivity to light and sound, slurred speech, glassy-eyed stare, seizures
Difficulty with short-term or long-term memory, confusion, slowed “processing” (eg, a decreased ability to think through problems), “fogginess”, difficulty concentrating,
Emotional symptoms can include:
Irritability, anxiety, depression, mood swings restlessness, aggression, decreased tolerance to stress, change in personality or behavior
Loss of libido, loss of menstruation, growth problems (children), fatigue, weight gain, low blood pressure, muscle weakness, blurred vision, poor concentration, chronic headaches or dizziness, muscle spasticity, early dementia/chronic traumatic encephalopathy (brain disorder)
How Is It Diagnosed?
Your physiotherapist will assess the patient’s signs and symptoms thoroughly including the orthopedic assessment cervical spine mobility and stability as injury to the cervical spine during concussion might lead to increased risk of headaches and dizziness. She will also assess cervical and shoulder muscles for increased tension and trigger points, vestibular and vestibule-ocular systems (to assess balance, coordination, dizziness, vertigo, nystagmus, etc.) and sensory integration. You will be also assessed for muscle strength, sight, smell, hearing, and memory tests. Most common tests for assessment of concussion used by your physiotherapist are:
- Cervicogenic Symptom Assessment
- Vertebrobasilar Insufficiency Testing
- Craniocervical Stability Testing
- Cervical Mobility Testing
- Dynamic Cervical Stability
- Joint Position Error Testing
- Trigger Points
- Vestibular Testing
- Balance Testing (Vision, Vestibular, proprioception)
- Benign Paroxysmal Positional Vertigo (BPPV) Testing – vertigo and dizziness
- Dix-Hallpike Test
- Roll Test
- Sidelying Test
- Ocular Motor Control Testing
- Smooth Pursuits
- Vistibulo-Ocular Reflex
- Visual Motion Sensitivity Testing (Visual Vertigo)
- Dynamic Visual Acuity (DVA) Testing
- Gaze Stabilization Testing
- Head Thrust Test
- Sensory Integration
- Balance Error Scoring System (BESS)
- Autonomic Nervous System
- Orthostatic Hypotension
- Exertion Testing (Buffalo Concussion Treadmill Testing)
How Is It treated?
After a thorough assessment of orthopedic, neurological, and cardiovascular systems described briefly above, your physiotherapist will plan a treatment protocol that prioritizes and addresses your specific symptoms. Treatment plan can include:
Rest and recovery is the cornerstone of concussion Management. A period of rest is essential after a concussion incident. Your physiotherapist will help you how and why you should keep away from certain activities and what activities are safe to do until it is safe to do otherwise. Your physical therapist will prescribe the rest and recovery program most appropriate for your condition.
Canalith Repositioning Manoeuvres (refer to BBPV treatment in Vestibular Rehabilitation Services)
Vestibular Rehabilitation is used to improve symptoms of dizziness and vertigo and includes: habituation exercises, gaze stabilization, Sensory substitution exercises). For more information please refer to Vestibular Rehabilitation Services on home page of this website).
Vision Rehabilitation includes exercises focusing on: fixations, smooth pursuits, correcting saccades, convergence, VOR exercises, and visual processing.
Vestibulo-Ocular Reflex Training and Gaze Stabilization Exercises. VOR reflex training involves repeated, rapid head movements when a visual target is in focus. The target can be stationary or moving. Gaze stabilization exercises should be performed daily, and dizziness is mostly provoked during these exercises. They involve head movements (slow to fast), body position (seated, standing, unstable surface), target distance (close to far), background (blank, busy, very busy static, moving, moving fast), and movement (sitting, standing, walking, and functional activities).
Sensory Substitution Strategies include balance exercises to make up for impairments in other sensory systems.
Headaches Treatment. Your physical therapist will evaluate the primary drivers of your headaches, and use the best strategies and exercises to improve them. Treatment might include mobilization of the joints, soft tissue techniques, stretching and strengthening exercises, eye exercises, and the use of modalities.
Exertion Therapy to restore strength and endurance. The physical and mental rest required after a concussion can result in muscle weakness, fatigue, physical deconditioning, metabolic disturbances and higher risk of injury upon return to play. Exercise rehabilitation after concussion has been found to improve autonomic regulation, increase global and cerebral blood flow, improve mood and depression, reduce systemic markers of inflammation, and improve cognitive function. Your physical therapist can help you with the right program when the right time comes. A sub-symptom threshold aerobic training will be advised by your physiotherapist in order to improve strength and function without worsening of the symptoms. To make sure you exercise below the symptoms threshold a Buffalo Concussion Treadmill Test will be performed at the baseline. Your physical therapist will design a therapeutic exercise program just for you, and closely monitor your symptoms as you participate in the program.
Return to normal activity or sport. As symptoms subside and you gain optimal strength and endurance without recurring symptoms, your physiotherapist will consider gradual return to play or daily living activities in the quick and efficient way. Gradual return to play should be safely monitored, ensure preventing symptoms return to avoid overloading the brain during the recovery time.
Bahareh specializes in the treatment of chronic pain, muscular and orthopaedic injuries. She received her doctorate degree in Rehabilitation Sciences from the University of British Columbia and her Baccalaureate and Master’s degrees in Physiotherapy.