Although I've taken several courses that address concussion assessment and treatment over the last few years, research is continually advancing our knowledge of guidelines. Here is a summary I've put together of some of the most recent literature which aims to answer the questions: Which patients require concussion rehabilitation and what does recent evidence suggest that concussion rehabilitation should include?
Assessment and Treatment Timelines
The most recent International Consensus Statement on Concussion in Sport (The Berlin Consensus Statement, April 2017) states that evidence-based treatment for persistent concussion symptoms includes cervical spine treatment, vestibular rehabilitation, psychological interventions, and controlled submaximal exercise (1).
The diagnosis of a concussion is a clinical judgment, made by a medical professional (1). A multi-faceted treatment approach seems to be the most effective approach to rehabilitation, and should begin immediately by obtaining a comprehensive history, performing a neurological exam to rule out serious pathology related to traumatic brain injury (TBI) or vascular insufficiency, and screening the cervical spine for signs of trauma. As a minimum, the health care team involved in the patient’s care should include a Family Physician and/or Sports Medicine Physician, and a Physiotherapist trained in concussion management. As required, patients may also benefit from a referral to see a psychologist, optometrist or dietician trained in concussion management.
Recent evidence suggests that starting rehabilitation as early as 10 days after injury improves recovery time and decrease the risk of developing post-concussion syndrome (PCS) (2). For individuals with PCS, a multifaceted assessment is needed to identify targeted treatments that may be of benefit (3).
Cervical, Vestibular, and Oculomotor Rehabilitation
The amount of force necessary to sustain a concussion is far greater than that which is needed to sustain a whiplash (4). As a result, nearly every concussion sustains a whiplash as well. The significance of this fact is that whiplash injuries can disrupt the vestibular system (causing dizziness and vision dysfunction), result in cervical joint and muscle tightness/inflammation (causing local pain, referred headaches, and contribute to a lack of concentration), and disrupt the reflexes between cervical-vestibulo-occular system.
In 2014, Schneider et al., published one of the first randomized clinical trials comparing a group receiving a combination of cervical and vestibular rehabilitation versus a control group that was given the usual protocol of rest followed by gradual exertion. Both groups received treatment from a physiotherapist at least once per week for 8 weeks, and had an average age of 15 years. In the treatment group, 73% of the participants were medically cleared within 8 weeks of initiation of treatment, compared with 7% in the control group. Individuals in the treatment group were 3.91 (95% CI 1.34 to 11.34) times more likely to be medically cleared by 8 weeks (2,5).
In 2017, Reneker et al., published another randomized clinical trial comparing individualized treatment plans consisting of manual therapy of the neck, vestibular rehabilitation, oculomotor and neuromotor retraining, to a control group. Subjects were permitted by a sports medicine physician to enroll in the trial if they had experienced concussive symptoms for at least 10 days, and were treated by a Physiotherapist for up to a maximum of 8 visits or until they were fully cleared to return to play by a blinded sport-medicine physician. The progressive treatment group achieved symptom resolution and clearance to resume full sport activities significantly sooner than the control group: 15.5 days versus 26 days, respectively. The authors concluded that a personalized treatment plan beginning as early as 10 days after concussion may be an effective option to shorten recovery time (6).
Exercise Recommendations Post-Concussion
Initiating physical activity within the first 7-14 days post-concussion has been associated with a decreased risk of developing PCS. These results have been noted in adolescents and adults (7-12). Several clinical trial have demonstrated significant improvements in symptoms, cerebral blood flow mechanics, and complete return to all pre-injury activities over a much faster timeline compared to control groups or sham therapies (i.e. stretching). This is true for both acute concussions and PCS (7-10). Research would suggest performing low-level aerobic exercise most days of the week, at 80% of their symptom-tolerated heart rate (13,14).
Summary: Providing Effective Treatment
In addition to a graduated ‘Return to Learn’, ‘Return to Work’, and/or ‘Return to Play’ protocol, patients recovering from concussions seem to benefit the most from specific therapies for the cervical spine, vestibular system, visual system, and cardiovascular system. Research suggests that focused rehabilitation that begins within the first 7 to 10 days after injury can significantly improve outcomes and decrease long-term symptoms in both children and adults.
1) McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Apr 26:bjsports-2017.
2) Schneider K, Meeuwisse W, Nettel-Aguirre A, Boyd L, Barlow KM, Emery CA. Cervico-vestibular physiotherapy in the treatment of individuals with persistent symptoms following sport-related concussion: a randomized controlled trial. Br J Sports Med. 2014 May 1;48:1294-8.
3) Feddermann-Demont N, Echemendia RJ, Schneider KJ, Solomon GS, Hayden KA, Turner M, Dvořák J, Straumann D, Tarnutzer AA. What domains of clinical function should be assessed after sport-related concussion? A systematic review. Br J Sports Med. 2017 Jun 1;51(11):903-18.
4) Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in post-concussion syndrome. The Physician and sportsmedicine. 2015 Jul 3;43(3):274-84.
5) Schneider KJ, Meeuwisse WH, Barlow KM, Emery CA. Cervicovestibular rehabilitation following sport-related concussion. Br J Sports Med. 2018 Jan 1;52(2):100-1.
6) Reneker JC, Hassen A, Phillips RS, Moughiman MC, Donaldson M, Moughiman J. Feasibility of early physical therapy for dizziness after a sports‐related concussion: A randomized clinical trial. Scand J Med Sci Sports. 2017 Dec 1;27(12):2009-18.
7) Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussion syndrome. Rehab Res Pract. 2012.
8) Leddy JJ, Cox JL, Baker JG, Wack DS, Pendergast DR, Zivadinov R, Willer B. Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. J Head Trauma Rehab. 2013 Jul 1;28(4):241-9.
9) Gagnon I, Grilli L, Friedman D, Iverson GL. A pilot study of active rehabilitation for adolescents who are slow to recover from sport- related concussion. Sci and J Med Sci Sports. 2015; 26(3):299–306.
10) Imhoff S, Fait P, Carrier-Toutant F, Boulard G. Efficiency of an active rehabilitation intervention in a slow-to-recover paediatric population following mild traumatic brain injury: a pilot study. J Sports Med. 2016.
11) Lal A, Kolakowsky-Hayner SA, Ghajar J, Balamane M. The Effect of Physical Exercise after a Concussion: A Systematic Review and Meta-Analysis. Am J Sports Med. 2017 Jun 1.
12) Zemek R, Grool AM, Aglipay M, Momoli F, Meehan WP, Freedman SB, Yeates KO, Gravel J, Gagnon I, Boutis K, Meeuwisse W. Relationship of early participation in physical activities to persistent post-concussive symptoms following acute paediatricpediatric concussion. Br J Sports Med. 2017 Jun 1;51(11):A20.
13] Schneider KJ, Leddy J, Guskiewicz K, Seifert TD, McCrea M, Silverberg N, Feddermann-Demont N, Iverson G, Hayden KA, Makdissi M: Rest and specific treatments following sport-related concussion: A systematic review. Br J Sports Med. 2017 Mar 24, 51:930-4.
14) Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010 Jan 1;20(1):21-7
Within the developed nations of the world, and on the topic of progress, Canada seems to always maintain the status of happy-mediocrity: Occasionally leading the pack, occasionally trailing behind, but most often hanging out, comfy-right-dab-smack in the middle! On the topic of primary disease prevention, Canada is currently in a state of ‘comfy’.
As with most pre-cursers to change, money (or the lack-thereof) has Canadian Health Policy makers starting to brain-storm. We all know that with the baby-boomer population reaching more advanced ages, healthcare costs are on the rise… and frankly there will just not be enough finances to adequately fund health care. In fact, as of 2011, seniors over the age of 65 represented just 14% of the population but were using 40% of hospital services in Canada, AND accounted for about 45% of all provincial and territorial government health spending (Canadian Institute for Health Information (CIHI) – Health Care in Canada, 2011: A Focus on Seniors and Aging). The question is, what can be done? I’m a physiotherapist, and obviously physical health and wellness is my niche. Here is my take.
I’d like to start with the idea that ‘for human-beings, the expression of life is movement’. Another way to look at this idea would be to understand that movement is how all living-beings interact with their own environment. For example: #1) The small muscles that allow us to move our eyes, allow us to see the environment around us. #2) The muscles of our hand allow us to handle and manipulate objects, show affection, build a home, or a cook meal. Therefore, if you cannot move well, your physical, emotional, and mental health will suffer. The conclusion should be that being able to move well is in many ways like a medicine – it can create positive changes in our health.
Unfortunately, day-to-day life can catch up to us as we age, and as a result we have a tendency to develop stiffness, pain, and become de-conditioned. These small problems often start to develop into larger and noticeable movement dysfunctions, changing the way that you move, and changing your focus from enjoying life to fixing the indicator of physical dysfunction – pain. If normal movement cannot occur, the human body adapts to these changes; Our vascular health deteriorates (heart, lungs, brain), we do not excrete as many toxins (leading to increased prevalence of cancers), our bone density decreases (leading to osteoporosis and arthritis), etc., etc.. The bottom line is that if we don’t move as much as we should, our internal health seriously deteriorates.
The answer to better health (either primary, secondary or tertiary prevention of diseases/disorders) must be an interdisciplinary approach. Family Physicians, Optometrists, Dentists, and specialized health practitioners advise their patients that routine check-ups are preventative in nature, and may help to ensure optimal health. While their services may be essential, many health concerns still go unrecognized, unaddressed, untreated, or do not received adequate follow-up. The American Physical Therapy Association’s House of Delegates has a position statement on annual check-ups expressing “All individuals should visit a physical therapist at least annually to promote optimal health, wellness, and fitness, as well as to slow the progression of impairments, functional limitations, and disabilities”. While the Canadian Physiotherapy Association does not yet have a position statement on this matter they have agreed to bring the matter to the CEO’s attention who will relay the idea to the Board of Directors.
My opinion on the matter is this: (1) Physiotherapists have superior knowledge of anatomy, physical function and dysfunction, treating holistically, and also treating very specifically. (2) Physiotherapists develop more meaningful relationships with their patients than many other health professionals due to the additional time spent with their patients. This should allow for greater insight into current impairments and lead to a more timely physical diagnosis which can help correct current dysfunctions, decrease the negative effects of a current diagnosis, and/or prevent future dysfunction from occurring. (3) This means added time at a lower cost, which provides greater value for the patient: More time for assessment, treatment, and follow-up. (4) Physiotherapy has can reduce risk factors and/or treat the most common co-morbidities in Canada (e.g. heart disease, diabetes, obesity, chronic disease). (5) Patients can benefit from physiotherapy at any age in terms of development, health promotion and wellness, maintenance of health, and disease prevention. (6) Patients who are provided with consistent and competent medical attention decrease or delay future health problem severity, maintain their quality of life for longer, and decrease the future financial burden on the public healthcare system.
So what is the drawback? Here are a select few:
(1) This service is currently advertised by a minority of physiotherapists in Canada – The general public does not even know this is an option!
(2) Even if the general public had awareness, the expectations of the 21st century seem that if something is hard to achieve or attain, its not worth the initial effort.
(3) Only a minority of people in Canada have benefit coverage for physiotherapy, and private physiotherapy services cost money. How many people in Canada are actually willing to pay out-of-pocket to help themselves when they are not in acute pain? The funding needs to be driven provincially/federally, or through private insurance.
Suggestions for physiotherapists: Create a sample assessment of what should be included in an Annual Physiotherapy Assessment. Include a full body screen – put your neuro, cardioresp, AND MSK skills to use. Start advertising it and explain the benefits! Lobby your local physiotherapy association to increase interest in the matter!
Suggestions for other readers: Find a therapist that specializes in Annual Physiotherapy Assessments and preventative health. Get an assessment and live a healthier life! If you found your assessment helpful, spread the news to your significant others!
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Jacob Carter lives and works in Canmore, Alberta. He combines research evidence with clinical expertise to educate other healthcare professionals, athletes, and the general public on a variety of health topics.