Physiotherapy management of concussion

Key Points

1. Concussion is a multifaceted injury requiring comprehensive care: Proper assessment, diagnosis, and management are essential for recovery and prevention of long-term effects.
2. Evidence-based guidelines improve treatment outcomes: Strong and moderate evidence provide the foundation for effective concussion management strategies.
3. Screening and early diagnosis are crucial: Timely identification and intervention can prevent complications and promote faster, safer recovery.
4. Active rehabilitation supports a gradual return to normal activities: Carefully monitored reintroduction to physical and cognitive tasks is critical for a successful recovery.
5. Clinical implication and study limitations: While evidence-based practices are essential, current research gaps underscore the need for ongoing studies to refine concussion management approaches.

What is concussion?

A concussion is a type of mild traumatic brain injury (mTBI) caused by biomechanical forces that result in a temporary disruption of brain function. This injury often occurs due to a direct blow to the head, face, neck, or other parts of the body, where the force is transmitted to the brain. Concussions can occur in various contexts, including sports, falls, motor vehicle accidents, and other physical impacts.

The symptoms of a concussion are diverse and can manifest immediately or develop gradually over the course of several hours to days. Common symptoms include headaches, dizziness, nausea, confusion, memory problems, balance issues, and sensitivity to light or noise. It’s important to note that concussions are primarily functional disturbances rather than structural injuries, meaning they typically do not appear on standard neuroimaging tests like CT scans or MRIs. Despite this, the impact of a concussion can be significant, affecting an individual’s physical, cognitive, and emotional well-being.

The complexity of concussion symptoms often necessitates a multidisciplinary approach to management, involving healthcare providers from various fields, including physiotherapy. Understanding the nature of concussions and the best practices for their management is critical for physiotherapists, especially when working with populations at higher risk, such as athletes and older adults.

Evidence-based recommendations for Physiotherapy management

In this section, we present key evidence-based recommendations for the management of concussions, drawn from strong and moderate levels of evidence. These recommendations serve as a guideline for physiotherapists in the assessment, intervention, and management of patients who have experienced a concussive event.

System of impairments or domains that need to be assessed

The following table outlines the key domains that need to be assessed in patients who have experienced a concussion, along with management strategies supported by high or moderate evidence. These domains represent the most commonly affected systems in concussed patients and are critical for a comprehensive physiotherapy evaluation.

Screening and diagnosis of a concussive event

Initial Screening

The initial screening for a concussion is a critical step in the management process. Physiotherapists are often the first healthcare providers to evaluate patients who have experienced a concussive event. Therefore, it is essential to identify the presence of symptoms that may indicate a concussion and to rule out any severe or life-threatening conditions that require immediate medical attention.

• Symptom Identification: The primary symptoms of a concussion include headaches, dizziness, nausea, confusion, and balance disturbances. Physiotherapists must be vigilant in identifying these symptoms during the initial screening process, as they can vary significantly between individuals.
• Screening for Emergency Conditions: Physiotherapists must also assess for signs of more severe injuries, such as cervical spine injury, intracranial bleeding, or other neurological conditions that may present similarly to a concussion but require urgent intervention. This includes checking for red flags such as severe neck pain, loss of consciousness, or worsening neurological symptoms.

Comprehensive Intake Interview

A comprehensive intake interview is essential for gathering detailed information about the patient’s history, the circumstances of the injury, and any pre-existing conditions that may influence their recovery. This interview should cover several key areas:

• Medical and Mental Health History: Understanding the patient’s past medical history, including any previous concussions or neurological conditions, is crucial. Additionally, a review of the patient’s mental health history can help identify any factors that may complicate recovery, such as anxiety or depression.
• Mechanism of Injury: Documenting how the injury occurred provides valuable context for the physiotherapy evaluation. This includes details about the impact, whether there was a loss of consciousness, and any immediate symptoms experienced by the patient.
• Early Management Strategies: It is important to note any initial treatments or self-care measures the patient has already undertaken. This information can guide the development of a tailored treatment plan and help avoid duplicating ineffective strategies.

Differential Diagnosis

Accurate diagnosis of a concussion is essential for effective management. Physiotherapists must differentiate between concussion and other conditions that may present with similar symptoms, such as whiplash, vestibular disorders, or post-traumatic stress disorder (PTSD).

• Triangulation of Information: Physiotherapists should gather information from multiple sources, including patient self-reports, observations from family members or witnesses, and clinical examination findings. This comprehensive approach helps ensure an accurate diagnosis and reduces the risk of missing subtle symptoms.
• Use of Symptom Scales: Symptom scales, such as the Sport Concussion Assessment Tool (SCAT), can be useful for quantifying the severity of symptoms and tracking changes over time. These tools provide a standardized method for assessing concussions and can support clinical decision-making.

Interventions and management for a concussive event

Effective management of a concussion involves a combination of education, therapeutic interventions, and close monitoring of the patient’s progress. The following table summarizes high and moderate evidence-based interventions that physiotherapists can implement to support recovery after a concussion.

Decision-making tree for the physiotherapist

Effective decision-making is critical in the management of concussion. Physiotherapists must carefully evaluate each patient’s unique presentation and adapt their treatment plan accordingly. The following decision-making tree outlines a systematic approach to planning and implementing care after a concussive event.

Step 1: Initial Assessment

• Screen for Emergency Conditions: Begin by ruling out severe or life-threatening conditions that require immediate medical attention, such as intracranial bleeding or cervical spine injury. If any red flags are present, refer the patient to the emergency department without delay.
• Conduct a Comprehensive Intake Interview: Gather detailed information about the patient’s medical history, the mechanism of injury, and any early management strategies they have undertaken. This will help inform the subsequent examination and intervention planning.

Step 2: Multisystem Examination

• Cervical Musculoskeletal Function: Assess the cervical spine for any dysfunction that may contribute to symptoms such as headaches or neck pain. This assessment should include range of motion testing, palpation for tenderness, and evaluation of posture and alignment.
• Vestibulo-oculomotor Function: Evaluate the patient’s vestibular and oculomotor systems, looking for signs of dizziness, vertigo, or visual disturbances. Consider using tools like the Dix-Hallpike test for BPPV or the Head Impulse Test to assess gaze stability.
• Autonomic Dysfunction: Assess the patient’s autonomic nervous system function, particularly in those who experience symptoms with physical exertion. This may involve monitoring heart rate variability, blood pressure changes, and the patient’s response to positional changes.
• Motor Function: Evaluate the patient’s motor function, including balance, coordination, and gait. Assessing the patient’s ability to perform dual-task activities can provide insights into their functional capabilities and highlight areas that need intervention.

Step 3: Intervention Planning

• Develop a Tailored Treatment Plan: Based on the results of the multisystem examination, create a personalized treatment plan that addresses the specific impairments identified. This plan should include a combination of manual therapy, therapeutic exercises, and patient education.
• Incorporate Education and Symptom Management: Ensure that the patient and their family understand the nature of concussions, the importance of gradual recovery, and strategies for managing symptoms. Provide guidance on rest, sleep hygiene, and pacing of activities to prevent symptom exacerbation.

Step 4: Monitoring and Progression

• Regularly Reassess Symptoms and Impairments: Schedule follow-up appointments to monitor the patient’s progress and adjust the treatment plan as needed. Use symptom scales and objective measures to track improvements and identify any new or persistent issues.
• Progressively Increase Activity Levels: As the patient’s symptoms improve, gradually increase the intensity and complexity of therapeutic exercises and functional activities. This should be done in a controlled manner, ensuring that the patient remains within their symptom threshold.

Step 5: Referral and Follow-up

• Refer to Specialists as Needed: If the patient’s symptoms persist or worsen, consider referring them to a specialist for further evaluation and management. This may include referral to a neurologist, neuropsychologist, or vestibular specialist, depending on the nature of the symptoms.
• Ensure Comprehensive Documentation: Document the patient’s progress, any changes to the treatment plan, and the rationale for referrals. This information is critical for continuity of care and may be necessary for communication with other healthcare providers.

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References

Quatman-Yates, C. C., Hunter-Giordano, A., Shimamura, K. K., Landel, R., Alsalaheen, B. A., Hanke, T. A., & McCulloch, K. L. (2020). Physiotherapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Academy of Orthopaedic Physiotherapy, American Academy of Sports Physiotherapy, Academy of Neurologic Physiotherapy, and Academy of Pediatric Physiotherapy of the American Physiotherapy Association. Journal of Orthopaedic & Sports Physiotherapy, 50(4), CPG1-CPG73. https://doi.org/10.2519/jospt.2020.0301

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