A Guide to Physical Therapy for Concussion

A concussion is a mild traumatic brain injury that may or may not be life-threatening but can seriously affect daily function and ability. If mild, symptoms may resolve completely in days. However, more severe concussions can lead to chronic disability.

Concussions can be difficult to diagnose, and often go untreated. An estimated 1.6-3.8 million sports and recreation-related concussions occur in the US every year¹, and nearly one-third of athletes have sustained an undiagnosed concussion.²

Heightened awareness of concussions has led to more recent research improving medical providers' ability to identify, diagnose and rehabilitate the effects of concussions. This guide will provide an overview of the symptoms, causes, diagnosis, treatments, and ways to trauma.

Table of Contents

• Understanding Concussion
• Symptoms of Concussion
• What are the Most Common Causes of Concussion?
• Identifying Concussion In Sports
• Diagnosing Concussion
• What to Expect from Physical Therapy
• The Stages of Concussion Rehab
• Preventing Concussion
• Is It Time to Seek Treatment?

Understanding Concussion

A concussion is an acceleration injury to the brain resulting in damaging changes of electrical charges in brain cells (neurons).³ The damage occurs when brain tissues undergo rapid forces of stretching, twisting, or compression.

A concussion occurs in two ways. One is damage directly to the head with a bump, blow, or jolt. The other is when the body is hit, causing the head to whip back and forth quickly, and the brain bounces or twists in the skull. A head injury can cause damage to the side of the brain directly impacted (known as a coup injury) and secondarily to the opposite side (counter-coup).

Most teenagers and young adults will recover completely in 2 to 3 weeks with proper rest and a gradual return to activity.⁴ Increased severity of symptoms and prolonged recoveries are more likely for those:

• Under the age of 5 and over the age of 65
• Between 15 and 24 years old playing contact sports
• Female athlete

Symptoms of Concussion

Symptoms of concussion can vary greatly as no two brain injuries are identical. The following list is not exhaustive but includes many of the common symptoms.⁴⁵⁶

• Confusion
• Difficulty concentrating or remembering events
• Brief loss of consciousness, disoriented
• Slurred/incoherent speech
• Sensitivity to cognitive stimulation (learning, work tasks, carrying conversations)
• Headache
• Unsteady/dizziness
• Nausea/vomiting
• Visual disturbances/sensitivity to light and sound
• Neck pain
• Decreased exercise tolerance, muscle endurance, and even muscle tone
• Altered autonomic regulation (body's ability to maintain temperature, blood flow, etc.)
• Delayed reaction time
• Emotional fluctuations that are abnormal to their typical self
• Irritability, fatigue, anxiety, sadness, drowsiness, lethargic
• Trouble falling asleep or drastic changes in sleeping habits

What are the Most Common Causes of Concussion?

The most significant risk factors for concussion include the following:⁷

• Falls
• Sports injuries — high-risk concussion sports include:⁸
  • Football
  • Hockey
  • Soccer
  • Rugby
  • Boxing
  • Bicycle motocross (BMX)
  • Bull riding
• Motor vehicle accidents
• Bicycle accidents
• Assaults

Identifying Concussion In Sports

If you see someone hit their head and they are motionless, slow to get up, dazed, dissented, or uncoordinated, some form of brain injury likely occurred. If the symptoms are mild and temporary, the should be monitored for the next few days to watch for any worsening of neurological symptoms.

This monitoring period is an ideal time to introduce a concussion-trained medical professional, such as a CityPT physical therapist. The CityPT clinician will screen for neurological severity and determine if a further medical examination is needed.

Returning to sport too soon can increase the risk of second impact syndrome (SIS). SIS can be lethal due to severe rapid swelling of an already concussed individual, sustaining more trauma to their brain.

When to Go to the ER

The emergency room (ER) is the worst place to begin recovery for those with a concussion and no life-threatening injuries. ERs are loud and have bright lights and increased stimulation which can significantly aggravate post-concussion symptoms.

Due to heightened awareness of concussion risks with sports participation, there are various tools to help parents, coaches, athletes and officials recognize when to take someone to the ER and what to watch for.

One useful and simple tool is the Concussion Recognition Tool 5 developed by the Concussion in Sport Group (CISG). Step one of this handout is to recognize a concussion and remove the injured athlete from the game.

Concussion Red Flags

After a blow to the head, the following signs and symptoms warrant a trip to the emergency department or a phone call for an ambulance.⁶

• Neck pain or tenderness
• Double vision
• Weakness or tingling/burning in arms or legs
• Severe or increasing headache
• Seizures or convulsions
• Loss of consciousness
• Deteriorating conscious state
• Vomiting
• Increasingly restless, agitated, or combative

Diagnosing Concussion

Concussions with mild symptoms are often left untreated and under-evaluated by medical professionals lacking specific concussion training. One reason is the lack of visible structural damage in medical imaging such as CT scans. Medical imaging may be necessary to rule out traumatic brain injury versus concussion when symptoms are severe.

The damage from a concussion is a functional disturbance in cellular metabolism, which causes temporary neuronal dysfunction.³⁹ The dysfunction is what causes the previously mentioned signs and symptoms.

The Need for Integrative Care

Multiple team members are needed to provide comprehensive care for individuals recovering from a severe concussion.

For example, for an older adult with a concussion, their healthcare team may include but not be limited to:

• Primary care doctor: An expert in the patient's comprehensive medical history
• Family members: Experts in the person's baseline — how they used to be/act/move/think/talk
• Neurologist: An expert in imaging and neurological testing
• Physiologist/psychiatrist: An expert in addressing mental health
• Physical therapist: A movement expert in restoring physical function and activity
• Occupational therapist: An expert in environmental adaptations and restoring the ability to complete activities of daily living

On the other hand, for a student-athlete following a concussion, their healthcare team may include but not be limited to:

• Primary care doctor: An expert in the patient's comprehensive medical history
• Family members: Experts in the person's baseline — how they used to be/act/move/think/talk
• School physiologist: An expert in addressing teenage mental health
• School counselor: A specialist that knows the student body and the demands of that student's particular setting. They may be the case manager for return-to-learn and return-to-play programs
• Teachers: An expert in the student's prior performance and essential to help coordinate workload with the student's tolerance and recovery speeds
• Physical therapist: A movement expert in restoring physical function and activity
• School trainer/Coach: An adult that understands the athlete's prior level of function and monitors the return to sport progress

What to Expect from Physical Therapy

All concussions need a period of rest following injury. Studies show this may be shorter than previously thought, and graded return to activity is essential. Returning individuals to activity is physical therapy's specialty, and thus plays a vital role in active rehabilitation post-concussion.

The amount of physical therapy and intensity will vary depending on your prior level of function and the severity of your concussion symptoms.

A CityPT physical therapist will take a thorough history and set goals for restoring the functions that are most important to you. Then they will complete an assessment and screen all neurological systems to determine your current ability level. They will also screen to determine if referrals to other specialists are appropriate.

The Stages of Concussion Rehab

Cognitive rest for 24 to 72 hours after a concussion is recommended. The next stage includes low-level cardiovascular exercise to stimulate blood flow to the brain and restore normal brain function.

As the brain's healing continues, therapy consists of a gradual return to activity and exposure to lights, sounds, cognitive demands, level of exertion, and coordination. Mild concussions are usually resolved in 2 to 3 weeks, though having more than one concussion or increased severity can lead to chronic symptoms and delayed recovery.

Leaving concussion untreated in athletes has a 2.48 increased risk of lower extremity musculoskeletal injury after returning to sport.¹⁰

Preventing Concussion

Below are guidelines to prevent a concussion in children under 5:

• Use of baby gates and blocking access to stairs and high places
• Use proper car seats in vehicles on every trip
• Never leave an infant where they can roll off an elevated surface

General recommendations for the prevention of sports concussions include:

• Helmets with a proper fit
• Proper tackling form (do not lead with your head, also illegal for this reason)
• Improved balance
• Proper core and neck strength
• Optimal level of physical fitness for your level of competition

The best way to prevent concussion in those over 65 is to prevent falls:

• Removing clutter from your house
• Have good lighting in hallways and areas that are used at night
• Avoiding bulky throw rugs

Is It Time to Seek Treatment?

Physical therapy can directly improve neck pain and dysfunction, vestibular imbalances (dizziness/unsteady), oculomotor sensitivities (symptoms provoked by eye movement or increased business of visual stimuli such as driving in traffic), tolerance to activity, and motor coordination.⁴

Are you ready to see if your post-concussion ailments can be improved? Physical therapy is an excellent resource for returning to your ideal life and daily routines.

CityPT has specialized clinicians who are waiting to learn about you. Book an appointment.

This guide is intended for informational purposes only. We are not providing legal or medical advice and this guide does not create a provider-patient relationship. Do not rely upon this guide (or any guide) for medical information. Always seek the help of a qualified medical professional who has assessed you and understands your condition.

References