Concussion (“mild” traumatic brain injury) and other forms of Traumatic Brain Injury (TBI) in sport has been a very popular topic of discussion in the past 10 years. The load of research on these topics has been staggering, and as a result the recommendations for treatment and prevention of these serious injuries seems to change quicker than the weather here in New England. Let’s take a look at the course of research and recommendation throughout the medical field and then we can focus on where your friendly neighborhood Physical Therapist fits into the picture.

Concussion occurs when your brain gets knocked against the inside of the skull due to a rapid stop and/or a rapid, violent change in direction. Direct contact of the skull on an outside object such as another player or the ground is not necessary to cause concussion. This is why helmets, while fairly effective at reducing the chance of severe skull injury, do not prevent concussion. Due to the violent nature of concussion, whether with or without external object contact, secondary issues such as orthopedic neck injury and vestibular interruption can occur.

At the turn of the century, the strongest recommendation for initial treatment of concussion symptoms was forced rest, both cognitive and physical. This reasoning was mainly based on the idea that the brain tissue, being of a physical nature and having sustained physical injury, requires a quiet healing environment to avoid long-term issues. Emerging research quickly began to downplay the idea of strict rest in favor of shorter and shorter periods of modified cognitive and physical rest from a week, to three days and most currently to almost immediate return to non-contact forms of aerobic activity which has shown in a large-scale study to lead to quicker reduction in concussion symptoms and quicker return to daily activities while avoiding long-term deficits. On the flip side of that recommendation remains the question of appropriate return to more aggressive or contact-related athletic activity. Common sense regarding a person’s current presentation of symptoms and activity tolerance play a roll in effective recovery from this type of injury.

So where does Physical Therapy enter into concussion treatment? As stated above, sustaining a concussion is an injury to the brain and is often accompanied by traumatic injury to the neck and inner ear vestibular system. It is also important to note the all concussions are not the same. Directionality of force-trauma will define which parts of the brain may be affected by a specific concussion episode, i.e. side-to-side trauma will injure different parts of the brain that front-to-back or other angles of force-trauma. It is therefore difficult to definitively define the ideal post-concussion protocol for return to normal activity without assessment of deficits by a skilled professional after each episode of injury. All orthopedic Physical Therapists have been trained at some point in neurological assessment and treatment. Concussion rehabilitation incorporates elements of both orthopedic and neurological treatment methods to resolve symptoms and restore function. Treatment may involve small, very specific, target-based neck exercises, manual vestibular correction, small and large amplitude functional motion and mobility training and palliative methods to resolve focal pain.
Traumatic brain injury of any type is serious business. Initial, professional medical assessment and intervention is extremely important in order to properly determine the level of injury and how to approach rehabilitation. Education regarding how and when to return to activity and what to avoid to reduce the chance of future injury can literally save a life. Be informed. Be well.

References:
Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135:213-223.
http://pediatrics.aappublications.org/content/135/2/213.long
Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther. 2010;34:87–93
http://www.ncbi.nlm.nih.gov/pubmed/20588094
Moser RS, Glatts C, Schatz P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. J Pediatrics 2012;161(5):922-926.http://www.ncbi.nlm.nih.gov/pubmed/22622050
Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms.Pediatrics 2014;133(2):1-6.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386420/
Gibson S, Nigrovic LE, O’Brien M, Meehan WP, The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27(7-8):839-842.
http://www.ncbi.nlm.nih.gov/pubmed/23758286
Moser R, Schatz P, Glenn M, Kollias K, Iverson G. Examining prescribed rest as treatment for adolescents who are slow to recover from concussion. Brain Inj. 2014; Early Online: 1-6 DOI: 10.3109/02699052.2014.964771 (e-published ahead of print October 1, 2014)http://www.ncbi.nlm.nih.gov/pubmed/25279423
Recommendation for Complete Rest Until Symptom-Free After Concussion May Not Be Best Approach for Recovery. American Academy of Pediatrics. April, 2016.
https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Recommendation-for-Complete-Rest-Until-Symptom-Free-After-Concussion-May-Not-Be-Best-Approach.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR:+No+local+token