Concussion Management Update 2020

Physical Therapy Assessment and Treatment of Concussions based on Clinical Practice Guidelines

Concussions or mild traumatic brain injuries occur in a wide variety of patients across the lifespan.  We see these injuries in sport participation but also as a result of falls with head impact, motor vehicle accidents, or work related injuries.   The result of the concussion can include a wide range of debilitating symptoms including dizziness, headaches, neck pain, balance deficits, visual deficits, and limitations in a patient’s ability to participate in their daily activities.  In recently released clinical practice guidelines, we see confirmation of the importance of prompt evaluation and treatment by a specialized physical therapist to mitigate the severity and chronicity of concussive events in patients of all ages.  A physical therapist who is well trained in managing concussions can act as a gate keeper for care during a concussive event and will work closely with your sports medicine specialist, primary care physician, or neurologist to determine an individualized treatment plan to a speedy recovery.  

First and foremost, a trained physical therapist will rule out severe pathologies through appropriate screening techniques.  This includes ruling out moderate/severe brain injury, cervical or skull fracture, or significant depression or cognitive changes.  Next, the physical therapist will examine for impairments in 4 major domains that typically manifest after concussive events including:

  1. Neck pain and mobility deficits
  2. Vestibular and visual impairments
  3. Aerobic or exertional impairments
  4. Motor Function including balance, coordination, and dual task capability

It is important to determine or prioritize which of these categories of deficits is most impactful on the patient’s function and address these areas first.  For example, oftentimes a patient will require treatment for their neck pain prior to successful participation in vestibular exercises. A trained vestibular therapist will be able to determine a plan of treatment that addresses deficits in each of these categories to propel the patient toward a fast recover from their concussion.  Treatments in the category of neck pain and mobility deficits may include neck stretching, manual therapies, and strengthening. Vestibular exercises may include treatment of BPPV, visual exercises that capitilize on strengthening the vestibular system, and motion sensitivity exercises. Aerobic deficits will be addressed through symptom-guided, progressive aerobic exercise training which may include a recumbent bike or treadmill.  Motor function interventions may include balance exercises, dual motor and cognitive tasks, or sport specific training. Finally, the therapist will implement extensive patient education including how to self-manage symptoms, how to implement appropriate rest, promote healthy sleep habits, and how to progressively and safely return to normal daily activities and sport.  

Finally, it is essential to understand that PROMPT treatment for concussions leads to faster return to work, school, and sport.  Those who participated in aerobic exercise in a safe manner sooner after a concussive event had less chronic disability from their injury.  As a consumer of the healthcare system, it is important for you to understand that most insurances allow access to a physical therapist via direct access-meaning there is no need for a script from your doctor.  Physical therapy can also be effectively implemented via telehealth to improve your access to care. The vestibular trained physical therapists at Willow Grove Physical Therapy have been at the forefront of concussion treatment for 15+ years and will implement an evidence based treatment plan that is comprehensive and effective in relieving your symptoms.  

Quatman-Yates CC, Hunter-Giordano A, Shimamura KK, et al. Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury. Journal of Orthopaedic & Sports Physical Therapy. 2020;50(4). doi:10.2519/jospt.2020.0301.