Managing Football-Related Concussions with Physical Therapy

A concussion is a mild traumatic brain injury that occurs when a sudden force causes the brain to crash into the skull, typically from a direct hit to the head or from a whiplash-type motion that can cause cognitive, sensory, and physical symptoms. Concussions are particularly high in the sport of football, resulting from helmet-to-helmet contact or whiplash-type motion from tackling. Physical therapists play a critical role in concussion management, utilizing an evidence-based, personalized, and gradual therapeutic exercise program to help athletes recover safely without exacerbating concussive symptoms.

Concussion: Causes & Symptoms

In the United States, there are more than 220,000 hospitalizations for traumatic brain injuries (TBIs) in a single year, or 600 per day. Concussions are the most common type of TBI. A concussion occurs when a sudden force causes the brain to crash into the skull, typically from a direct hit to the head or from a whiplash-type motion (front to back or side to side).

The soft and sensitive tissues of the brain are surrounded by fluid and are protected by the bones of the skull. However, when a powerful impact occurs to the head or body (causing a whiplash motion), this causes the head and brain to shift back and forth. This sudden force can propel the brain to move inside the skull, which can stretch and damage brain tissue and cause chemical changes that can affect normal brain function.

Symptoms may occur immediately after impact. However, concussion symptoms may also appear hours or even days later, so it is important that a person who is suspected to have experienced a concussion be monitored for several days to assess for symptoms. Concussion symptoms can show up cognitively, be mood and sensory-related, or involve blood dysregulation. Loss of consciousness after a concussion can occur, but only in about 10% of concussions and signifies a more severe concussion.

Common symptoms of a concussion:

• Cognitive: confusion, dazed appearance, amnesia, delayed response to questions, difficulty concentrating or reading, brain fog, short-term memory problems, slowness in thinking and acting

• Mood: anxiety, depressions, irritability, feeling overwhelmed, low energy or motivation, mood or personality changes

• Sensory: blurred vision, nausea with motion, change in or loss of taste or smell, ringing ears, losing balance

• Blood Dysregulation: headache, fatigue, nausea, dizziness, occasional heartbeat irregularities, sensitivity to light or noise, sleep disturbances, feeling of pressure in the head, persistent neck pain, vomiting, or slurred speech

After an athlete sustains one concussion, they are 4-6 times more likely to sustain another concussion. If players return to play before fully healing from the first concussion, they place themselves at risk of more severe injuries like post-concussion syndrome, in which symptoms persist for weeks following the event without resolution. Post-concussion syndrome can affect up to 30% of all concussion patients.

Football-Related Concussions

Football-related concussions are multi-faceted and require coordinated care from a sports medicine doctor, a physical therapist, and the team’s athletic trainers. A recent study by the NCAA indicated that men’s football has the highest annual rate of sports-related concussions and the highest annual increase in the number of concussions compared to other collegiate sports, with 26.1% of players in a collegiate football program experiencing a concussion at some point in their careers.

From 2012-2019 in the NFL, an average of 242 players per year sustained concussions. In the last decade, there has been increased awareness of the impact of multiple concussions on NFL players and the development of CTE, a degenerative disease that is caused by repetitive hits to the head over a period of years that can cause memory loss, personality changes, confusion, and dementia.

Among high school football players, 20% are likely to experience a concussion every football season; research has shown that football is responsible for more than 60% of concussions in high school sports. Players that have the highest percentage of concussions are linebackers (defensively) and running backs (offensively).

Nearly half of all concussions occur during running plays, with two-thirds of concussions resulting from player-to-player contact when tackling. Helmet to helmet contact is the most common source of concussive impact. While football helmets protect against head trauma like a skull fracture, they protect the skull, not the brain. When a player is hit hard on a play, the force of the impact can still cause the brain to move inside the skull and become concussed despite the protective helmet.

Researchers are taking steps to create safer football gear, such as helmets designed to absorb impact better than traditional helmets or sensors in helmets that send an alert when impact exceeds a certain threshold to be able to pull a player for evaluation in real time as well as track each player’s impact trends over time. However, these innovations are in the nascent stage. It is therefore critical that football players of all ages receive comprehensive and customized concussion management with a physical therapist to prepare for a safe return to competition.

Physical Therapy Concussion Management

Physical therapists play a critical role in concussion management, utilizing an evidence-based, personalized, and gradual therapeutic exercise program to help athletes recover safely without exacerbating concussive symptoms.

Following a concussion, it is important that the athlete rests for 24-48 hours. However, research has shown that early active rehabilitation post-concussion that does not exacerbate symptoms is highly beneficial. The physical therapist first conducts a thorough examination to assess concussion symptoms, including a dizziness handicap inventory, a post-concussion system inventory assessing the cervical spine and neck, a vestibular exam, and an exertion treadmill test to measure the patient’s tolerance for exercise and in order to appropriately prescribe graded aerobic exercise as part of the treatment protocol.

Physical therapy concussion treatment can include:

• Vestibular rehabilitation therapy (VRT): Vestibular rehabilitation is used to address dizziness and balance issues following a concussion. The vestibular system of the inner ear is a sensory system that helps maintain balance, providing the brain information on head position, motion, spatial orientation, and stabilization of the head and body during motion. VRT can involve gaze stabilization, habituation, and balance training exercises.

• Balance training: static and dynamic balance exercises that require coordinated movement, completion of dual tasks, and transitioning from static to dynamic positions to improve postural stability during movement.

• Manual therapy: soft tissue mobilizations, primarily to the neck muscles and tissues, to alleviate myofascial restrictions and tightness in the neck that may be contributing to headaches and discomfort.

• Neck muscle treatment: targeted stretching and strength training of the neck muscles can help reduce tension in the neck muscles and improve neck muscle endurance.

• Graded sub-symptom aerobic exercise can shorten concussion recovery time and help the brain adapt to the increased physiological demands of activity over time in a controlled environment with careful monitoring. Mild aerobic activity increases blood flow and oxygen to the brain, which promotes brain healing post-concussion. A structured aerobic exercise program with gradual progression of intensity and duration is an essential component of concussion management and allows the patient to regain fitness without exacerbating symptoms.

• Dual task training: dual task training is a key aspect of physical therapy after a concussion. Dual task training involves performing motor and cognitive tasks simultaneously. This is critical as football players engage in dual tasks while on the field; they must regulate both internal processes (joint position sense or vestibular function) and respond to external cues like the ball, opponents, and teammates in order to modify movement and perform the intended motor task (running, cutting, blocking, catching, or tackling) in a time-constrained environment during a football game.

• Return to sport testing: once an athlete achieves higher intensity aerobic exercise without exacerbating symptoms, they can begin to engage in sport-specific activities. The therapist will assess the athlete’s ability to complete sports drills to determine whether the athlete is ready to start the return to play protocol.

Per the CDC, there are specific guidelines for concussion management and a progressive return to play protocol. Each step must be performed symptom-free and with the clearance of a medical provider before progressing to the next step:

[Source]

Research has confirmed that early physical therapy concussion management is highly effective and allows athletes to return to sport safely and in a timely manner. A recent study noted that those athletes post-concussion who received individualized physical therapy within 10 days post-concussion were nearly 4 times more likely to be cleared to return to play (RTP) after eight weeks.

Further research shows the benefit of exercise and early physical activity after a concussion, noting that athletes experience fewer post-concussive symptoms after sub-symptomatic aerobic exercise when compared to the traditional concussion standard of care. One study found that those concussion patients who underwent a comprehensive physical therapy program post-concussion were more likely to be medically cleared to return to sport within 8 weeks of treatment than the control group. The treatment group received cervical spine physical therapy interventions including manual therapy to the thoracic and cervical spine and therapeutic exercise as well as vestibular rehabilitation, range of motion exercises, and postural education. In the treatment group, 11 of the 15 individuals returned to sport within 8 weeks of treatment, whereas only one of the 14 in the control group returned to sport in that timeframe.

A concussion is a mild traumatic brain injury that necessitates appropriate, timely, and well-monitored treatment to achieve optimal recovery and a safe return to activity. A physical therapist is qualified to manage a concussive patient’s treatment using evidence-based protocols and a rehabilitation program for positive post-concussive outcomes.