Concussion Management

What is a Concussion?

A concussion is a mild traumatic brain injury that can be caused by a direct blow to the head, face, or neck. It can also be caused by an impact somewhere else in the body causing a force transmitted to the head.

A concussion may or may not involve the loss of consciousness.

The traumatic force causes shearing of axons creating a metabolic process that impairs function within the nerves. The metabolic impairment is caused by a decrease in cerebral blood flow despite the increased need for oxygen and energy stores to help the body return to a normal cellular environment.

It is the metabolic and vascular issues that are presumed to cause the symptoms of a concussion.

The metabolic crisis can persist up to 30 days, giving rise to persistent concussion symptoms.

For some individuals, signs and symptoms may development over minutes to hours following the injury.

No abnormality is seen on standard structural and neuroimaging studies, as the acute clinical symptoms lead to a functional disturbance rather than structural. (Berlin Consensus Guidelines, 2016)

Common Signs and Symptoms:

A concussion is suspected with 1 or more of the following symptoms:

Physical Signs: Dizziness, balance problems/unsteadiness, headache, nausea or vomiting, fatigue/sleep disturbance, blurry vision, sensitivity to light or sound, loss of consciousness, amnesia, neurological deficit, tinnitus (ringing in the ears)
Cognitive Impairment: Concentration, Memory Problems, Confusion, fogginess
Emotional or Behavioural Changes: Sadness/Depression, Anxiety, Irritability

The formal diagnosis of a concussion can only be given by a physician, nurse practitioner or neuropsychologist.

What Should I Do:

If you or someone else may have had a concussion, you should:

Immediately discontinue the activity you were doing when the concussion occurred.
Seek medical advice immediately. Various tests may be performed including a CT or MRI (which cannot identify the concussion but may be used to rule out other injuries including skull fractures or bleeding).
Do not drive for at least 24 hours.
Cognitive and physical rest is important for the first 24-48 hours.
Symptoms could worsen over the next few days. Consult a health professional before returning to your current level of activity.

Recovery (How Long Will it take to feel better?)

No two concussions are alike.

Many factors can contribute to the time it takes to recover including:

Severity of concussion
Health previous to the concussion
Age
History of prior concussions

Sports related concussions resolve within 7-10 days, with about 10% of people experiencing symptoms beyond 2 weeks (Willer & Leddy, 2006).

Recovery from concussions that are not sports related generally happen in the first 3 months, however 33% of people will experience symptoms beyond this date (Levin et al., 1987; Rimel et al., 1981).

A concussion can resolve within a short period of time, however for some, these symptoms persist leading to Post-Concussion Syndrome.

Post-Concussion Syndrome is defined through the DSM-IV as:

Cognitive deficits in attention or memory
And at least 3 of the following: fatigue, sleep disturbance, affective disturbance, apathy, or personality change, headache, or dizziness.

The International Classification of Disease ICD-10 defines Post-Concussion Syndrome as:

History of head trauma prior to onset of symptoms by maximum of 4 weeks, with or without loss of consciousness
Symptoms in 3 or more of the following categories:
- Noise intolerance, malaise, fatigue, headache, dizziness
- Subjective report of concentration, memory, or intellectual difficulties. This is without evidence of neuropsychological impairment.
- Insomnia
- Decreased alcohol tolerance
- Preoccupation of symptoms and fear of brain damage. Hypochondriacal concern, and adopting sick role.

It is important to seek advice from a healthcare professional trained in Post-concussion syndrome management for follow-up and monitoring

What is included in a Physiotherapy Concussion Assessment?

Your physiotherapist will begin your assessment with discussing the mechanism of your injury and the symptoms you are experiencing.

The remaining of the assessment will involve objective testing to establish what causes the reproduction of your symptoms.

An assessment of your neck as well as neurological tests will take place as a screen.

Following this, your physiotherapist will assess balance and dizziness, as well as complete a vestibular and ocular assessment.

Physiotherapy can help with the management of your concussion symptoms, with the goal of getting you back to regular function and everyday activities

What is included in Physiotherapy Treatment for a Concussion?

Each treatment plan is individualized, and is based on the person’s goals and symptoms.

Your treatment plan may include:

Education: pacing/planning, return to work and sport, and increase in stimulation (ie. Light/noise), mindfulness training, monitoring of symptoms and activity
Cervical spine assessment and appropriate treatment
Eye exercises to address visual impairments
Vestibular rehabilitation
Balance/proprioception training
Introduction to gentle exercise

When can I return to work or activity?

Time off of sport or work is recommended, especially within the first 24-48 hours after sustaining a concussion.

A plan for gradual return to the activity or work based on tolerance is recommended.

Your physiotherapist will work closely with your employer or coach to develop a return to work or sport plan.

Concussion Courses:

Concussion Management Workshop – Concussion Rehab Works

Management of Post-Concussion Syndrome – R2P™ Concussion Management

Vestibular Rehab | Special Topics - What To Do When It’s Not BPPV: Challenging Vestibular Disorders, including Post-Concussion Syndrome