In 1997, The American Academy of Neurology defined concussion as "a trauma-induced alteration in mental status that may or may not involve a loss of consciousness." Our understanding of concussion has changed significantly since then, and while definitions vary, one thing is certain-concussions are mild traumatic brain injuries.
The Centers for Disease Control and Prevention (CDC) defines concussion as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical force secondary to direct or indirect forces to the head. The CDC estimates that nearly 3.8 million incidences of sports-related concussions occur every year and that there are on average about 1.7 million people who sustain a traumatic brain injury annually. The duration of concussion symptoms is highly variable and may last minutes to months or longer. Symptoms can be physical, cognitive, emotional or sleep related, and may or may not involve the loss of consciousness. Concussions tend to range from mild to severe.
Typically, following a mild concussion, there may be a brief change in mental status or consciousness. Following a severe concussion there will be an extended period of unconsciousness or amnesia. Recovery from a concussion occurs within seven to 10 days following a sport-related concussion and within three months for a non-athlete.
Incurring a Concussion
A concussion can occur following a motor vehicle accident or sport-related injury, or by simply bumping the head. Approximately 10 percent of military personnel returning from Iraq may have sustained concussive injuries. Concussions can be diagnosed clinically during the acute or chronic stages. The Zurich Consensus statement reports that a "concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolved spontaneously."
It is common to have patients report symptoms acutely following a concussion. However, it is becoming more common to evaluate patients with chronic complaints who were never acutely diagnosed with a concussion. The complex constellation of symptoms that persist for an extended period of time after an initial concussion, affecting up to 5 to 20 percent of patients, is called post-concussion syndrome (PCS).
The World Health Organization (WHO) defines PCS as "a syndrome that occurs following head trauma and includes any number of the following symptoms: 1) headache, 2) dizziness, 3) fatigue, 4) irritability, 5) difficulty concentrating and performing mental tasks, 6) impaired memory, 7) insomnia and 8) reduced tolerance to stress, emotional excitement or alcohol." The Diagnostic and Statistical Manual of Mental Disorders has established different criteria for PCS. In order to diagnose a patient with PCS, the patient must have a "history of head injury that includes two of the following: loss of consciousness for five minutes or more, posttraumatic amnesia of 12 hours or more, or onset of seizures within six months of injury." In addition, the PCS diagnosis can be further evidenced by a patient's having difficulty concentrating, learning or remembering, as well as by the presence of three of the following over three or more months post-concussion: easy fatigability, sleep disturbance, headache, vertigo/dizziness, irritability, anxiety, depression, personality change or apathy.
Individually these signs and symptoms may appear non-threatening and can be dismissed as stress, the flu or migraines. However, patients will often present with a number of the symptoms listed in tables 1 and 2. It is estimated that 50 percent of concussed high school athletes fail to report an injury or minimize symptoms, since they may not have experienced trauma to the head and few have experienced LOC. That is the reason why concussions are often missed and secondary impact syndrome-a second concussion within a short period of time that typically is minor but results in significant symptoms-is on the rise.
To recognize concussion, a health care professional must look for signs such as headache, confusion, fogginess, slow reaction time, behavioral changes and/or sleep disturbance. Commonly, standardized tools are used by neuropsychologists on the field, including the Standard Assessment of Concussion (SAC), Sports Concussion Assessment Tool -2 (SCAT-2), which includes coordination and balance screen, or the Military Acute Concussion Evaluation (MACE).
CAT scans detect concussion less than 10 percent of the time (detects hemorrhage or edema), and MRIs are abnormal in 10 to 57 percent, by detecting white matter changes, small contusions and hemorrhage.
Advanced techniques for diagnosing concussion include functional MRI, MR spectroscopy, diffusion tensor imaging, single photon emission CT, positron emission tomography and EEG.
Neurocognitive assessment is valuable for diagnosing athletes, but the value is optimized when baseline testing exists. This testing can be paper and pencil tests (e.g., memory, concentration, impulse, reaction time) or computerized tests (ImPACT). Athletes, post-concussion, often demonstrate decreased postural stability, particularly with alterations to visual conditions or support surface. Balance testing with divided attention may be more sensitive than neurocognitive testing at determining dysfunction. Unfortunately, there is little research considering traditional vestibular PT measures (DGI/FGA). The best current evidence for testing is the Sensory Organization Test and BESS protocol.
Due to the amount of dizziness seen in post-concussive patients (55 percent of sports-related concussions), vestibular therapy is often warranted. Dizziness is associated with visual activities approximately 55 percent of the time. It is frequently associated with head motion and with getting out of bed or with bending over.
The causes of dizziness in the population can include BPPV (low incidence), labyrinth concussion, perilymphatic fistula, seizures, post-traumatic migraine, and central (brainstem concussion), autonomic (postural hypotension), and ocular motor abnormalities. The potential mechanisms for ongoing dizziness include dysregulation of BP, an affected gaze stability mechanism, ocular motor issues and post-traumatic migraine-related dizziness.
As previously mentioned, post-concussion management is best done with a team approach, including a neuropsychologist, a physician and a vestibular PT. The team can also include an athletic coach/trainer, neuro-otologist, neuro-ophthalmologist, psychologist and cognitive therapist. Standard interventions include removal from play/activity, minimized cognitive exertion, academic accommodations/decreased work load, limited reading, no video games or outside activities like malls/parties, migraine prevention education and/or medication.
Physical therapists should monitor all post-concussive symptoms when treating patients. A HEP should be given to be performed one to two times a day. Exercises should include gaze stability (done slowly), habituation for motion sensitivity, balance retraining, and exercises for convergence issues. With all treatments, secondary symptom exacerbation should be avoided.
There is no one medication for management. Pharmacological treatments are considered when symptoms don't subside spontaneously or interfere with daily life. Headaches are often treated with NSAIDs, Imitrex, SSRIs, tricyclics, or beta blockers. It is recommended to assess the cervical spine, history of pre-existing headaches, visual acuity, sinus infection or CSF leak.
Back to Work and Play
Since the symptoms of a concussion and PCS are somewhat varied and patient specific, it can be difficult to determine when it is appropriate for a patient to return to work or a specific sport. This should be a collaborative decision involving the patient/parent, the physical therapist, doctor and coach. It is important for coaches, athletes and parents to be well informed regarding the signs and symptoms of concussion. Every team should have a protocol established to manage potential concussions.
These protocols should include preseason screening, an immediate plan of action following a possible concussion, medical referral source, recovery progression plan, and a standard clearance prior to return to play.
Prior to return to play, an athlete should be asymptomatic while at rest, and should be capable of performing sub-maximal aerobic exercise without increasing symptoms of PCS. Leddy et al. concluded "that exercise treatment for PCS is beneficial if the exercise program is individualized, if its progression is controlled in a quantitative manner, and provided it is administered at the appropriate time after brain injury."
Careful consideration should be taken prior to returning to a contact sport because once someone sustains a concussion the likelihood they will develop PCS following a second concussion increases. This phenomenon is known as second impact syndrome, and although it is a rare problem, mortality rates are 50 percent with brain stem failure in two to five minutes after a second injury. Noise sensitivity, history of previous migraine headaches or concussion and amnesia are additional risk factors that increase the risk for developing PCS following successive concussions.
Post-concussion syndrome can also result from a non-athletic injury. In those instances, it may be difficult to determine the appropriate steps to recovery. Typically employees have never been pre-screened, so there will be no baseline data. Most employers have not established a protocol for PCS that allows an employee to modify a work load accordingly. These patients will most likely benefit from work modifications, time away from the stresses of work and possibly vocational rehabilitation.
The future of concussion management is upon us. Changes have been implemented, as far as evaluation and management of concussions, in most professional sports. These changes have stemmed from what some international groups have done. In 2002, FIFA, IOC and IHF formed the Concussion in Sport (CIS) group. This group emphasizes the utility of post-injury neuropsychological testing as a "cornerstone" of proper post-injury management. All health care professionals would agree that education to players, parents, coaches and health care employees is imperative to ensure proper post-concussion management. Certain variables can affect outcomes of concussion management, including amnesia, age (younger patients have a protracted recovery), exertion, migraine history/symptoms, gender (female athletes have longer recovery times), history of concussions and fogginess (longer recovery times).
Concussion is a functional (not structural) injury to the brain with serious consequences if clients are mismanaged. Management should involve a multidisciplinary approach to improve a client's dizziness, imbalance and impaired gaze stability. The key component to PT management is to proceed slowly.
For a list of resources, visit www.advanceweb.com/PT.
Joseph R. Caccavo Jr. is a clinical specialist at Kessler Institute for Rehabilitation in West Orange, NJ. Heather Sleece is a physical therapist proficient at Kessler who is also certified in vestibular therapy.
As a result of the increased awareness of concussions among athletes, there has been a push within the profession to develop a standard protocol for treatment following a concussion. In 2010, The American Physical Therapy Association's Board of Directors issued a position on concussions, which states that concussions should be evaluated and managed by a multidisciplinary team of licensed health care professionals, of which physical therapists are an integral part.
Their position emphasized that a team of health care practitioners skilled in the knowledge of brain injury should be available to remove individuals suspected of having suffered a concussion from their activity and perform an assessment for concussion. Further, individuals should be prohibited from further participation in their sport until a written clearance from a health care professional who is trained in concussion management can be obtained.
In January 2011, bill HR 469 was introduced by Rep. Timothy Bishop (D-NY) calling for the development of concussion management guidelines that address the prevention, identification, treatment and management of concussions in school-aged children. At present time, the bill has been referred to committee following some hearings and briefings, said Nate Thomas, PT, DPT, MBA, associate director of federal government affairs for APTA. There are no bills currently in the Senate regarding this issue.
"There is interest, and with so much media attention and public awareness, the thought is maybe with beginning of school and fall sports seasons [there would be] a buzz-but it doesn't seem like it will happen this fall since we still have other issues before Congress following their August recess," Dr. Thomas said.
The APTA supports HR 469 as an important piece of legislation that would ensure concussion management plans are created, educating students, parents and schools about identification and management of concussions, he said. The proposed legislation also lists the various health care professional groups and PTs are specifically included, he said.
Many states are starting to pass their own legislation regarding concussions. APTA's department of state government affairs is helping state chapters in states where similar legislation has been introduced, he said. "There's a great deal of momentum at the state level in passing similar bills within the past year. The number of laws passed this year have doubled between 2009 and 2010; there are now 31 state laws," he said.
Those states follow Zackery Lystedt's Law, which originated in 2009 in Washington state as the result of a case involving a young man who had incurred a concussion while playing high school football. He was injured in a game and continued to play, ending up in a coma. The law has been endorsed and used as state model, and the Bishop bill is based on the same principles.
The legislation dictates that states set up minimum guides for schools to follow in:
1) Identifying the signs and symptoms of concussions and for school personnel, coaches and health care personnel in the schools.
2) Identifying guidelines for removal from activity and return to play.
3) Identifying which personnel are authorized to determine when students with concussions can return to sports or other activities.
APTA convened a working group to discuss how it should concentrate efforts on the policy, and many PTs were part of that group, Dr. Thomas said. "For us, the key issue is that PTs are a part of the multidisciplinary team, so the student athletes will have access to PTs," he said. "Our endorsed language states that PTs can help make return-to-play decisions, as health care professionals trained in identifying concussions."
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