Concussion

Post-Concussion Syndrome Rehabilitation Management

What is a concussion? The most recent consensus statement on concussion in sport is defined as a “complex pathophysiological process affecting the brain, induced by traumatic biochemical forces”. Concussions may result from a traumatic force contact to the head, face, neck or body. A loss of consciousness is not mandatory in the diagnosis of a concussion. (1)

Symptoms may include:

  • Chronic low-grade headache symptoms
  • Dizziness or light-headedness
  • Increased sensitivity to sounds or light
  • Blurred vision
  • Nausea and vomiting
  • Ringing in the ears
  • Delayed cognitive processing
  • Increased confusion
  • Memory loss
  • Impaired concentration
  • Neck pain
  • Decreased energy
  • Severe mood changes—Feeling sad, anxious or angry

The majority of individuals (80-90%) that are subjected to a sport related concussion recover within a 7 to 10 day time frame. (1) Symptoms lasting beyond a normal recovery period are classified as (PCS) or Post-Concussion Syndrome. The World Health Organization defines PCS as persistent symptoms lasting greater than one month. (2) The diagnostic and statistical manual of mental disorders (DSM-IV) classifies PCS as symptoms lasting greater than 3 months. (3)

Immediately following a concussion the primary treatment is that of physical and cognitive rest. Exercise activity in the acute post-concussion period will increase the brain metabolic activity demands at a time when energy reserves are compromised due to being utilized for healing and injury repair. (4) A return to exercise too soon following a concussion injury will also alter the production of (BDNF) brain derived neurotrophic factor which promotes neuronal healing. (5)

Beyond the acute stage post-concussion syndrome treatment has typically consisted of rest, education, neurocognitive rehabilitation and pharmaceutical management of symptomology. Recently studies have been investigating the efficacy of additional treatment options including vestibular rehabilitation (8), visual training (7), cardiovascular training (13) and treatment of cervical spine dysfunction (6).

Recent studies have shown exercise to be effective in promoting recovery for PCS. (13) Benefits of exercise include:

  • Increased parasympathetic activity and improve autonomic regulation (9)
  • Increased cerebral blood flow (10)
  • Increased brain derived neurotrophic factor production (BDNF) with improved cognitive performance (11)
  • Improved mood, sleep and depression (39, 41)
  • Reduction in systemic markers of inflammation (42)

Physical Therapy rehabilitation for post-concussion syndrome will be patient specific and tailored to address the specific symptoms with which each patient presents. Treatment options may include:

  1. Soft tissue mobilization and myofascial release to restore muscle and fascial pliability and ROM in the head and neck regions.
  2. Joint mobilization as required per assessment findings.
  3. Deep neck flexor and extensor muscle training.
  4. Postural deficit corrections.
  5. Graded cardiovascular program. (Bike, Treadmill, Elliptical)
  6. Vestibular dysfunction treatment. (BPPV, VOR)
  7. Balance dysfunction treatment.
  8. Visual processing dysfunction treatment.
  9. Craniosacral treatment for cranial bone mobilization.
  10. Patient education on activity pacing and maintaining an activity level below the symptom threshold.

Recovery from a concussion is dependent on many factors. These factors include the severity of the injury, the portion of the brain receiving the injury, the age of the patient, and the general level of health of the individual prior to the injury.

 

REFERENCES

  1. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus Statement on Concussion in Sport: The 3rd International Conference on Concussion ins Sport Held in Zurich, November 2008. Journal of Athletic Training. 2009; 44(4): 434-448.
  2. World Health Organization (WHO). International statistical classification of disease and health related problems, 10th 1992.
  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th 1994.
  4. Vissing J, Galbo H, Haller R. Exercise fuel mobilization in mitochondrial myopathy: A metabolic dilemma. Annals of neurology. 1996; 40(4):655-662.
  5. Barde YA. Trophic factors and neuronal survival. Neuron. 1989; 2:1525-1534.
  6. Weightman MM, Bolgla R, McCulloch KL, Peterson MD. Physical Therapy Recommendations for Service Members with Mild Traumatic Brain Injury. Journal of Head Trauma Rehabilitation. 2010; 25(3): 206-218.
  7. Kapoor N, Ciuffreda KJ. Vision Disturbances Following Traumatic Brain Injury. Current Treatment Options in Neurology. 2002; 4: 271-280.
  8. Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to Full Functioning after Graded Exercise Assessment and Progressive Exercise Treatment of Post-concussion Syndrome. Rehabilitation Research and Practice. 2012; 1-7.
  9. Carter JB, Bannister EW, Blaber AP. Effect of Endurance on Autonomic Control of Heart Rate. Sports Medicine. 2003; 33(1): 33-46.
  10. Doering TJ, Resch KL, Steuernagel B, Jurgen B, Schneider B, Fiscger GC. Passive and Active Exercises Increase Cerebral Blood Flow Velocity in Young, Healthy Individuals. American Journal of Physical Medicine and Rehabilitation. 1998; 77(6): 490-493.
  11. Griesbach GS, Hovda DA, Gomez-Pinilla F. Exercise-induced Improvement in Cognitive Performance after Traumatic Brain Injury in Rats is Dependent on BDNF Activation. Brain Research. 2009; 1288: 105-115.
  12. Scully D, Kremer J, Meade MM, Graham R, Dudgeon K. Physical exercise and psychological well being: a critical review. British Journal of Sports Medicine. 1998; 32(2): 111-120.
  13. North TC, McCullagh P, Tran ZV, Effect of Exercise on Depression. Exercise and Sport Science Reviews. 1990; 18(1): 379-416.
  14. Ford ES. Does Exercise Reduce Inflammation? Physical Activity and C-Reactive Protein Among US Adults. Epidemiology. 2002; 13(5): 561-568.