#BrainInjuryAwarenessMonth: Physical Therapy Concussion Management

March is Brain Injury Awareness Month. One of the most common brain injuries is a concussion, a mild traumatic brain injury that can lead to physical, cognitive, and behavioral symptoms. Effective, timely, and well-monitored treatment after a concussion is critical for a full recovery and safe return to sport. Physical therapists are qualified to manage concussions through evidence-based treatment protocols and a personalized rehabilitation program that includes vestibular rehabilitation, manual therapy, balance training, and a graded, progressive exercise program.  

Concussion, Brain Injury, & Symptoms

A concussion is a temporary mild traumatic brain injury that can result in disrupted neurological function and can cause a wide range of cognitive, physical, and behavioral symptoms. Seventy-five percent of the estimated 1.7 million traumatic brain injuries sustained by Americans each year are a concussion or another form of a mild traumatic brain injury.

A concussion can result from a direct blow to the head or a direct blow to another part of the upper body that transmits force indirectly to the head, such as a sports collision, fall, or car accident. This can cause an unpredictable injury to the brain. Symptoms vary from person to person depending on which area of the brain is affected and injured.

Common symptoms of a concussion include:

Cognitive

• Difficulty with short or long-term memory

• Confusion

• Slowed processing

• Fogginess

• Difficulty concentrating

Physical

• Headache or migraine

• Dizziness

• Difficulty with balance and coordination

• Nausea/vomiting

• Fatigue

• Difficulty sleeping or increased sleepiness

• Double or blurred vision

• Sensitivity to light and noise

• Slurred speech

Behavioral

• Irritability

• Depression

• Nervous or anxious 

Less than 10% of individuals who experience a concussion experience loss of consciousness. Symptoms can start immediately or soon after an injury and may evolve over the following hours or days. Most symptoms resolve with 10 to 14 days. If symptoms persist past this timeframe, the individual may have post-concussive syndrome (PCS) in which symptoms such as headaches, fatigue, dizziness, and trouble concentrating continue.

While most concussions are relatively mild, it is critical to have a full medical evaluation and establish a safe, customized plan of treatment for the concussive patient, particularly if the patient experiences PCS.

Physical Therapy Concussion Management

Physical therapists can effectively manage concussion injuries through evidence-based treatment and a careful, personalized rehabilitation program. Physical therapists work with a multidisciplinary team of doctors to ensure the concussive patient receives proper, timely care for optimal recovery. The therapist conducts a thorough examination to evaluate the concussive patient’s symptoms, including a dizziness handicap inventory; a post-concussion system inventory that assesses 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.

After a concussion, a 24 to 48-hour period of rest is recommended. After that period, it is important to gradually and progressively return to physical activity while staying below the symptom threshold, meaning engaging in activities without exacerbating symptoms. Physical therapists help patients do so safely and gradually until they can return to daily activities, work, and sport without symptom exacerbation.

Physical therapy treatment for a concussion includes:

•  Vestibular and vision rehabilitation: Vision issues and vestibular system-related symptoms, like dizziness, are common complaints of post-concussive patients. Nearly 60% of athletes report having a vestibular impairment and symptoms after a sports-related concussion.

  • Vision and vestibular symptoms are related to problems with the balance centers of the brain, the visual system, and the muscle and joint sensors of the neck. Vision issues can also contribute to difficulty concentrating.

  • The physical therapist utilizes vestibular rehabilitation therapy, which is an exercise-based program designed to reduce vertigo and dizziness and address gaze instability and imbalance issues. The therapist also guides the patient through oculomotor exercises to improve vision clarity and stabilize the patient’s gaze.

•  Balance testing and training: Balance training involves balance and gait training drills in combination with vestibular rehabilitation therapy. This helps the patient regain proprioception (spatial awareness of the body) and neuromuscular movement control in a controlled, safe environment.  

• Manual therapy and neck pain treatment: Neck pain after a concussion is fairly common and can be treated through manual therapy and targeted neck strengthening and stretching exercises. During trauma to the head, the neck muscles contract and tighten in order to provide protection, which can then result in chronic tension as the muscles stay in protective mode following a concussion and its lingering symptoms (headaches, dizziness). This places strain on the neck muscles and cervical spine. Manual therapy involves joint mobilizations to relax and reduce tension in the neck muscles, thereby increasing blood flow to the brain.

• Graded aerobic exercise: Engaging in gradual, sub-symptom exercise training has been shown to help shorten 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 healing in the brain. A structured exercise program with gradual progression of intensity and duration allows the patient to regain fitness without exacerbating symptoms.

 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.