We are getting better and better at recognizing and managing concussions, and it is increasingly known that physiotherapists can play an important role in this. However, I think that there is still a lack of good education given to clients after their concussive event, or diagnosis of a concussion, about what they should do and who they should be seeing to help.
In Toronto, I worked very closely with a physio who specializes in concussions and dizzy people (as he would say). Previously concussions would take up between 10-20% of my caseload, and this could be sports injuries, motor vehicle accidents, or unfortunate falls and day to day accidents that could happen to anyone. I would often see clients with concussions in the clinic who had not been educated on the important early management, and they could be 6 weeks plus since the concussive event and not managing symptoms well at all, failed a return to work or sport, and have no structure to their management. It was frustrating that they were not being given easy, accurate information at diagnosis that would help them!
The training and mentorship I received has given me a very good baseline in helping those with a concussion, however, it is an area of care at the moment that is continuing to advance because of all of the research being done to help us understand concussions better. It requires constant reading of new literature and staying up to date on best practices. Clinical Practice Guidelines were released in 2020 for Physiotherapists. Again this is not a medical protocol or gold standard, but a guideline of the literature to help with our clinical reasoning skills and expertise.
This is a summary of the recommendations that physiotherapists should follow when managing concussions. If you are going through a concussion at the moment, I would hope that you are doing the majority of the points below.
The term concussion is often used interchangeably with mild traumatic brain injury. It is defined as a traumatic injury that affects the brain and is induced by biomechanical forces transmitted to the head by a direct blow to the body.
It is generally thought that 80-90% of concussions resolve in 7-10 days, and if it is lasting longer than this then there should be intervention from a multidisciplinary team that involves a detailed assessment and personalized plan should be put in place based on the findings. Other terminology that is used is that the first 7-10 days is an acute concussion, then up to 12 weeks is a sub-acute concussion, and symptoms lasting longer than this are referred to as post-concussion syndrome. It is important to recognize these time frames as it influences our decision making with regards to rehab strategies and plans.
With regards to physiotherapy, the assessment of a client after a concussive event should determine the appropriateness of physiotherapy intervention. There are 4 domains that align with a physios scope of practice that would indicate that a physiotherapist should be involved in the management. These are
Cervical (neck) musculoskeletal impairments
Exertional tolerance impairment
Motor function impairments
Physiotherapy examination should be focused around these domains, and the interventions should be planned on the findings.
Recommendations for Physiotherapy Intervention
Physios must educate patients and families about symptoms and limitations.
If BPPV is a potential impairment then repositioning interventions should be used.
Symptom guided progressive aerobic exercise training should be implemented when exertional intolerance is evident, or the person is planning on returning to vigorous physical activity.
Physios must educate patients about self-management, including
the importance of relative rest, not strict rest,
the benefits of progressive re-engagement in activities,
safe return to activity,
potential signs to see a physician
Should design personalized intervention plans
Should refer patients for further consultation and follow up with other health care providers as indicated, specifically for
mental health symptoms,
other potential medical diagnoses
Individualized vestibular and oculomotor rehab should be used if the therapist has the appropriate expertise.
Physios should implement motor function interventions that address identified impairments, such as
Coordination and control,
work and recreation activity-specific tasks
Physios may implement aerobic exercise when exertional intolerance is not evident
Patients should be triaged into 1 of 2 categories
Patients with movement-related impairments and dysfunction who are good candidates for physio
Patients with no movement-related impairment or dysfunction
Therapists who lack appropriate training in vestibular and oculomotor rehab should refer patients on to clinicians with appropriate expertise
Should regularly document symptoms and provide reassessments
What do I do?
Fortunately, my training and mentorship has been excellent, and I do all of the above. When I see concussion clients we go through a thorough assessment using a number of standardized and recognized tests and outcome measures that we are able to repeat later on to track progress, and can highlight different issues if they come up. Based on the findings of the assessment and my discussion with the client and support network, I then determine the appropriateness for physiotherapy, and we produce a plan based on education and symptom management. Depending on the findings of the assessment we will then also include a progressive aerobic exercise program, exercises for impairments such as balance, vestibular/oculomotor exercises, and neck rehab.
I also write a detailed report for your family doctor and make specific recommendations for referral to any other health professionals that may be of benefit to each case. I will complete reassessments often and continue to update all professionals working on your team. Communication is vitally important.
We are fortunate at this time that there is so much research being produced regarding concussions and recovery. It is vitally important that your health professionals are up to date in this area, and competent in producing an appropriate plan for your care!
Thanks for reading, please do not hesitate to reach out and ask me any questions. I am happy to discuss individual cases with you and see if it is something I may be able to help with.
Quatman-Yates CC, Hunter-Giordano A, Shimamura KK, et al. Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury.J Orthop Sports Phys Ther. 2020;50(4):CPG1‐CPG73. doi:10.2519/jospt.2020.0301