John Seivert: Concussion — Current management leads to improved recovery
In the April 2020 Journal of Orthopaedic and Sports Physical Therapy (JOSPT), there was a complete update and recommendations on evaluating and treating patients with concussion/mild traumatic brain injury (TBI). This was as a result of current evidence and new findings that will enhance our management of patients with concussions. The simple reason for the continued increase in the focus on this issue is the increased incidence of kids with concussions and the media around the American professional football players. The 2015 movie “Concussion” starring Will Smith brought the focus on how poorly the NFL was managing professional football players. New research shows that if a TBI goes undetected and not properly treated, it can result in long-term brain damage and may even prove fatal. While the first hit can prove problematic, the second and third can cause permanent long-term brain damage. We have all seen the top professional football quarterbacks that have stepped away from the game after too many TBI’s. Many of these professional athletes are getting well-needed treatment for these multiple TBI’s with great results due to the recent recommendations from the experts in the management of TBI’s.
Incidence of TBI
Researchers have found a 60% increase in incidence between 2007 and 2014 (143% increase in 10-14-year olds and 87% in 15-19-year olds). Half of all concussions evaluated in the emergency room are sports-related in 8-19-year old’s. American football has the greatest number of TBIs, and it also has the greatest number of participants. Forty-seven percent of all reported sports concussions occur during high school football. This is followed by Boys’ ice hockey. Then Girls’ soccer, Boys’ lacrosse and girls’ lacrosse, boys’ soccer, and finally boys’ wrestling to round out the top eight culprits of TBI.
Signs & Symptoms of a Concussion
Concussions are not always obvious. Some people may pass out, but most do not. Ninety percent of diagnosed concussions do not involve a loss of consciousness. The symptoms of concussion can range from mild to severe, and can last for days, weeks, or even months if not treated properly. If you or anyone you know has sustained a head impact, it is essential to look for signs of a concussion.
Here are a few of the common symptoms of a concussion:
Physical symptoms of a concussion: dizziness, problems with balance, nausea/vomiting, balance problems, sensitivity to noise/light, blurred vision, and headaches.
Mental symptoms of a concussion: Confusion, difficulty remembering, difficulty concentrating, trouble paying attention, and loss of focus.
Sleep symptoms of a concussion: a marked change in sleeping, either more or less than usual and/or unable to fall asleep.
Emotional symptoms of concussion can be: Easily angered or upset, nervousness and anxious feelings, sadness, crying more than usual, and depression.
Diagnosis and treatment of a TBI
A concussion is a direct blow to the head, face, or neck, or an impulsive force elsewhere on the body that is transmitted to the head. The proper diagnosis of a TBI requires medical expertise and should incorporate as many professionals as necessary to support the return-to-play or work process. In our community, almost all medical doctors are well versed in treating this patient population. A blow to the head, resulting in a concussion causes a functional disturbance to the brain and not a structural injury to the brain. Therefore, the physical exam is the process of diagnosing a TBI, not by scans such as a CT or MRI.
Treatment for Concussion
Once a patient has been diagnosed with a concussion, the treatment may vary depending on the severity. If the trauma is mild, they may need a few days’ rest, no sport, and possibly some mild pain reliever. A quick word about REST: this means the patient needs physical and cognitive rest until they are symptom-free. Mental rest from electronics, school, and physical rest. However, there is no evidence that rest beyond 24-48 hours is needed. One study even showed that strict rest beyond two days post-injury does not improve outcomes and may increase symptom reporting. A high-quality study comparing adolescent athletes who followed an aerobic exercise program in the “rest 10 days after a sports-related concussion” to a group that followed a “progressive stretching program” found that early aerobic exercise may help speed recovery (10-18.5 days for the aerobic group versus 13 to 23 days for the stretching group). These new studies on the use of aerobic activity in the treatment of patients with concussions are now widely accepted and used in the medical community.
Physical therapists are trained in managing patients with TBI’s. The neurological exam and treatment include an assessment of the mental (cognitive) status, reaction time, visual and verbal processing, sensory processing (e.g., vision & vestibular), motor function (e.g., coordination, gait, balance), and oculomotor (eye movement) function. The experts in concussion management recommend that acute intervention should be individually prescribed progressive physical therapy that includes manual techniques, vestibular rehabilitation, oculomotor and neuromotor retraining delivered to individuals while symptomatic, as early as 10 days after a sports-related concussion.
The most significant finding in improving results with treating patients with a concussion has been found to be the education given to the patient AND their family. Recent studies have shown a marked improvement in outcomes when the family is educated about the healing process and why the physical therapists are doing the unique tests and treatments while in PT, along with the timeline for recovery.
In summary, with the recent evidence in the management of concussions, there has been a change in treating these patients. We are now intervening earlier with less time resting and educating the patient and his/her family on the rehab process. This is reminiscent of how we changed our management of low back pain. One to two days of rest is ample time to rest an injured tissue, and then the progressive activity is indicated.
John Seivert is a doctor of physical therapy and he has been practicing for 34 years. He opened Body Logic Physical Therapy in Grass Valley in 2001. He has been educating physical therapists since 1986. Contact him at bodylogic2011@yahoo. com.
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