Concussion

Definition:

Concussion is a complex pathophysiological process affecting the brain. It is the result of an injury caused by a biomechanical force i.e., a direct blow to the head, neck, or face or from a blow to another part of the body with a mechanical force transmitted to the head. The individual may not experience a loss of consciousness (LOC) with the incident. In fact, only approximately 10% of concussions involve Loss of Consciousness.

What is a Concussion?

A concussion is often referred to by doctors as a “mild Traumatic Brain Injury.” Both terms are used when a person experiences a change in normal brain function for no longer than a minute following trauma. Concussions are usually not life-threatening, but their effects can be serious.
Effects are usually temporary but can include headaches and problems with concentration, memory, balance, and coordination.

A concussion is a mild traumatic brain injury that results from a bump, violent jolt, or blow to your head that disrupts normal brain function. A concussion can also be caused by a hit to your body that is strong enough to cause your head to forcefully jerk backward, forwards, or to the side.

Concussions stretch and bruise nerves and blood vessels and cause chemical changes in your brain that result in a temporary loss of normal brain function. A single concussion usually doesn’t cause permanent damage to your brain. Multiple concussions over a lifetime may result in structural changes in your brain.

The force of a hit can cause a concussion on the part of the brain that was directly hit or on the opposite side of the brain (as the brain tissue itself moves from the force of the blow and hits the opposite side of the skull).
Different areas of the brain control different functions, so blows to your head can predict your symptoms.
A concussion to the back of the brain causes balance issues, fogginess, neck pain, and difficulty concentrating.
These symptoms usually predict a longer recovery from a concussion.

People at greater risk for concussion:

1. Older people and children ages 4 and under due to their risk of falls.
2. Adolescents due to bike accidents and sports-related head injuries.
3. Military personnel due to exposure to explosive devices.
4. Anyone involved in a car accident.
5. Victims of physical abuse.
6. Anyone who has had a previous concussion.
7. Adolescents are at higher risk of concussion than any other age group. Researchers think this is because their brains are still developing. The brain is still laying down its neural pathways and adolescents’ necks are typically weaker at this age than in young adults and older people.

Causes of Concussion

• Brain tissue is soft and squishy. It’s surrounded by cerebrospinal fluid, which acts as a cushion between it and the hard protective exterior, the skull. A concussion occurs when your brain bounces or twists inside your skull or experiences rapid, whiplash-type back-and-forth movement that causes it to collide with the inside of your skull. This brain movement stretches and damages brain cells and leads to chemical changes in the brain.
• These injuries cause your brain not to function normally for a brief period of time and result in the signs and symptoms of concussion.
• Motor vehicle accidents falls, and sports injuries are common causes of concussions. Any sport that involves contact can result in a concussion.
• Among children, most concussions happen on the playground, while bike riding, or when playing sports such as football, basketball, ice hockey, wrestling, or soccer.

• Falls. Falls from bed or a ladder, down stairs, in the bath and other falls are the most common cause of traumatic brain injury overall, particularly in older adults and young children.
• Vehicle-related collisions. Collisions involving cars, motorcycles, or bicycles — and pedestrians involved in such accidents — are a common cause of concussion.
• Violence. Gunshot wounds, domestic violence, child abuse, and other assaults are common causes. Shaken baby syndrome is a traumatic brain injury in infants caused by violent shaking.
• Sports injuries. Concussions may be caused by injuries from a number of sports, including soccer, boxing, football, baseball, lacrosse, skateboarding, hockey, and other high-impact or extreme sports. These are particularly common in youth.

Symptoms of Concussion

The most common symptoms of concussion include:

• Headache. (This is the most common symptom.)
• Nausea or vomiting.
• Confusion.
• Temporary loss of consciousness.
• Balance problems/dizziness/lightheadedness.
• Double or blurry vision.
• Ringing in the ears.
• Sensitivity to light and noise.
• Feeling tired or drowsy.
• Changes in sleep patterns (sleeping much more or less than usual or can’t sleep).
• Trouble understanding and/or concentrating.
• Depression or sadness.
• Being irritable, nervous, and anxious.
• Feelings of being “just not right” or in a “fog.”
• Difficulty paying attention, forgetful, memory loss.

Mood Symptoms

• Irritable
• Sad, depressed, tearful
• More emotional than normal
• Nervous or anxious

It’s very common for infants and toddlers to hit their head. Concussions in these little ones can be difficult to diagnose because they can’t say how they feel. Look for these signs of concussion in children:

• Bumps on the head.
• Vomiting.
• Being irritable, cranky.
• Will not eat or nurse.
• Change in sleep pattern, sleepy at unusual times.
• More fussy than usual, won’t stop crying despite being comforted.
• Blank stare.

How soon do concussion symptoms appear?

Concussion symptoms usually appear within minutes of the head injury.
However, some symptoms may take several hours to appear.
Symptoms can change days later; others can develop when the brain is stressed with use.

When to see a doctor?

1. Severe headache or a headache that continues to get worse over time.
2. Seizures or convulsions.
3. Loss of consciousness (greater than 1 minute).
4. Severe dizziness, loss of balance or problems with walking.
5. Repeated vomiting (more than once).
6. Increasing confusion, such as difficulty recognizing people or places.
7. Clear, watery discharge from the nose or ears
8. Bloody discharge from the ears.
9. Numbness, weakness or tingling in arms or legs.
10. Unusual, bizarre or irritable behavior.
11. Slurred speech.
12. Pupils that are bigger than normal or unequal in size.
13. Extreme drowsiness, difficulty waking from sleep, or fainting.

Seek emergency care if an infant has any of these symptoms:

1. Loss of consciousness.
2. Vomiting.
3. Seizures.
4. Discharge or blood coming out of the nose or ears.
5. Unable to open eyes on their own.
6. Difficulty waking from sleep.
7. Swelling of the soft spot; bruising, especially around the eyes or behind the ears; swelling of the head; skull fracture.

Diagnosis:

You may also have a neurovestibular exam as part of the first evaluation. This exam looks for vestibular, balance, and vision problems that often occur with a concussion. Your doctor may order imaging tests — such as MRI or CT scans — to make sure there’s no bruising or bleeding in your brain.

Neurological examination

After your doctor asks detailed questions about your injury, he or she may perform a neurological examination. This evaluation includes checking your:

• Vision
• Hearing
• Strength and sensation
• Balance
• Coordination
• Reflexes

Cognitive testing

Your doctor may conduct several tests to evaluate your thinking (cognitive) skills during a neurological examination. Testing may evaluate several factors, including your:

• Memory
• Concentration
• Ability to recall information

Imaging tests

Brain imaging may be recommended for some people with signs and symptoms such as severe headaches, seizures, repeated vomiting or symptoms that are becoming worse. Brain imaging may determine whether the injury is severe and has caused bleeding or swelling in the skull.

A cranial computerized tomography (CT) scan is the standard test in adults to assess the brain right after injury. A CT scan uses a series of X-rays to obtain cross-sectional images of your skull and brain.

For children with suspected concussion, CT scans are only used if there are specific criteria met, such as the type of injury or signs of a skull fracture. This is to avoid radiation exposure in young children.

Magnetic resonance imaging (MRI) may be used to identify changes in your brain or to diagnose complications that may occur after a concussion.

An MRI uses powerful magnets and radio waves to produce detailed images of your brain.

Outcome Measures

Difficulties arise in diagnosing a concussion as a result of the hugely variable presentations of each individual injury. Matters can be further complicated by the time pressures clinicians find themselves under in sporting events. It is therefore important that the clinician is aware of tools available to them to assist them in making an accurate diagnosis of concussion.

Cognitive Function:
Assessment of cognitive function is an essential component of assessment. A number of short neuropsychological tests assessing memory and attention are available. These include the Maddocks’ questions, Sports Concussion Assessment Tool 5 (SCAT 5) and Standardized Assessment of Concussion (SAC).

Maddocks’ Questions:
This is a list of 8 standardized memory assessment questions. These have been proven to be more reliable than the use of general orientation questions.

Benefits:

Relatively short to administer
More sensitive than standard orientation questions

Limitations:

There is no guideline indicating the cut off for return to play-for example if a player answers only 1 of the 8 questions incorrectly should they be removed from the field of play/ do all 8 questions have to be asked?
There is a dearth of literature investigating the reliability and validity of these widely used questions.
Cannot be used as a stand-alone tool-need to be used in conjunction with the clinicians’ judgement.

SCAT 5:
A concussion assessment tool suitable for use for people aged 13+. The test includes an assessment of the player’s level of consciousness using the Glasgow Coma Scale, memory assessment using Maddocks’ questions, symptom evaluation, cognitive screen, physical, balance, coordination, delayed recall and neck examination. Pre-season baseline measurements can be used as useful comparisons to help in the identification of a concussion.

Benefits:

Incorporates a number of different concussion assessments into one tool.
Available as a phone app

Limitations:

The SCAT 5 takes between 15-20 minutes to complete
The SCAT 5 is newly published and as such has not yet been assessed for reliability and validity. Its forerunners the SCAT 2 and SCAT 3 have also not had their reliability and validity assessed in any large scale studies.
Despite its’ wide-scale use in sport, the SCAT2 has its critics, with a meta-analysis in 2013 criticising its’ design and scoring. It is found that the test has low test-retest reliability and thus questioned its suitability for use in diagnosing a concussion.
A high score on the SCAT does not necessarily mean that a player is not concussed, as symptom onset can be delayed.
It must be noted that there have been reports of athletes purposefully scoring a low baseline measurement to avoid being taken off the pitch when concussed

Standardized Assessment of Concussion (SAC):
Assesses orientation, immediate memory, concentration and delayed recall. It takes ~6 minutes to administer.
Sensitivity: 80-94% Specificity: 76-91%

Benefits:

Relatively short time to administer
Assess a number of different functions commonly affected by concussion

Limitations:

Certain studies have reported the sensitivity of the SAC to be only 80%, meaning that a large number of concussed players would not be identified using the tool.
No cut-off scores to determine the diagnosis of a concussion, have been established for the SAC

Post-Concussion Symptom Scale/Graded Symptom Checklist:
Consist simply of a list of symptoms of concussion that must be checked for in the athlete either by trained personnel or the athlete themselves. A baseline must be established prior to use. Studies calculate a sensitivity of between 64–89% and a specificity of between 91– 100%.

Benefits:

Simple to use
Relatively short time to administer

Limitations: Poor sensitivity means that a number of athletes with a concussion would not be identified using this assessment alone.

Balance Error Scoring System (BESS):
Balance assessment tool. Takes ~ 5 minutes to complete. Assesses postural stability in a number of different stances on both firm and foam surfaces. Scores range from 0-60 with lower scores indicating better balance.

Benefits:

Postural stability testing has been shown to be a reliable and valid tool for objectively assessing the motor domain of neurological functioning.
Relatively short time to administer
Simple administration consists of standardized instructions and requires no training
Examines the effects of mild head injury on postural stability without the need for expensive equipment
Can be performed in almost any environment

Limitations:

Does not assess any other functions commonly affected in concussion
Very poor sensitivity of between 34–64%, specificity of 91%

Sensory Organization Test:
Uses a force plate to test a player’s ability to maintain their balance while orientation information available to somatosensory and/or visual inputs are altered.

Limitations:

Requires use of a force measuring plate and is therefore impractical for sideline use.
Expensive test as equipment required for assessment.
Low sensitivity of between 48-61% reported. Specificity found to be between 85-90%

Canadian CT Head Rule
This measure consists of a list of signs and symptoms used to decide whether a head injury or concussion warrants a scan.

Benefits:

Simple to use
High-risk factors were seen to be 100% sensitive when predicting the need for neurological intervention.
Medium risk factors were 98.4% sensitive for predicting clinically important brain injury.
A cross-sectional study which compared the use of Canadian CT head rule which compared its use to the gold standard in the detection of head injury the Computed Tomography (CT) Scan and agreed that it is an excellent decision-making tool.

Limitations:

Low specificity (49-60%) means that a number of patients without concussion will be recommended for a scan if using the tool. However, it is more important that the tool has high sensitivity and thus that no patients with a concussion are missed using the tool.

As can be seen above a number of different diagnostic tools are available to the clinician to assist them in recognizing a concussion. Each has its advantages and disadvantages as discussed above. None of these tools should be used in isolation. Rather, they should be used in conjunction with the clinician’s clinical judgement. Combining diagnostic tests is likely to increase the accuracy of concussion diagnosis when compared to using individual tests. However, at present, the best combination of tests to improve concussion identification has not been established.

Complications:

• Long-term complications of concussion include:
• Post-traumatic headaches. Some people experience concussion-related headaches up to seven days after a brain injury.
• Post-traumatic vertigo. Some people experience a sense of spinning or dizziness for days, weeks or months after a brain injury.
• Post-concussion syndrome. This is a condition in which you experience concussion symptoms for weeks or even months (instead of days) after experiencing a concussion. Such symptoms may include ongoing dizziness/spinning, headache, memory and concentration problems, mood swings, depression, anxiety, irritability, personality changes, insomnia (can’t sleep) and excessive drowsiness.
• Higher risk of anxiety and depression (especially if there’s been multiple concussions).
• Structural brain injuries from multiple concussions. People who have had several head injuries in their life are at higher risk of long-lasting impairment. Chronic traumatic encephalopathy is one example of a brain condition linked to repeated blows to the head.
• Problems with memory, naming, and word-finding.
• Dementia.
• Second impact syndrome. Rarely, experiencing a second concussion before signs and symptoms of a first concussion have resolved may result in rapid and usually fatal brain swelling.

Risk factors:

A number of different factors associated with a higher risk of experiencing a concussion have been outlined in the literature. These are outlined below.

Sex:
A higher rate of concussion has been recorded for males in all sports. However, it appears likely that this is a result of the larger number of males participating in the sports investigated. It was suggested that the association of certain sex with higher rates of concussion varies across different sports, with a higher rate of concussion for females in both soccer and basketball. Other studies have suggested that the higher incidence of concussion noted in females may be a result of greater reporting of concussive symptoms by female athletes, and as a result of their smaller head size and neck strength relative to their male counterparts.

Type of Sport:
As stated above, the risk of concussion associated with sports varies across different sports. Australian rugby and American football are associated with the highest incidence of concussion, while a lower risk is associated with sports such as baseball, softball, volleyball and gymnastics. Several high-quality studies have associated soccer with the greatest concussion risk for female athletes.

Position:
The athlete’s playing position can also be associated with higher/lower concussion risk. In American football greater risk has been associated among linebackers, offensive linemen, and defensive backs compared to receivers. Currently, there is insufficient evidence to associate player position with greater/lesser concussion risk in other sports.

Athlete-related Factors:
Several factors specific to the individual athlete have been associated with greater concussion risk, including a body mass index greater than 27 kg/m2.
Training time of less than 3 hours also weekly likely increases the risk of concussion.
Currently in the literature, there is insufficient evidence to determine links between age and competition level and risk of concussion.

Treatment:

You need physical and mental rest to recover from a concussion.
Although you’ll need more rest and sleep than normal, you don’t need 100% complete rest.

Instead of stopping activities entirely, learn to recognize the triggers that bring on concussion symptoms. Start back slowly, in small amounts. When symptoms occur, back off and rest. It’s okay to do some of the activities that don’t make you feel worse. Limit any activities that worsen your symptoms.

For example, activities that may bring on symptoms include:

• Texting/spending time looking at your smartphone screen.
• Reading.
• Watching television.
• Playing video games.
• Listening to loud music.
• Doing any physical activity.
• As your symptoms improve, you can continue to add more of your activities back into your day.

Medication for headache in concussion: Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS), such as naproxen and ibuprofen should not be taken soon after a suspected concussion has occurred. These medications mask symptoms and thin the blood, which may increase the risk of bleeding. This is of special concern in elderly who fall and hit their head, as it’s not uncommon for these people to already be taking these drugs. After a concussion is diagnosed, if pain medication is needed, acetaminophen is a safer option. Symptoms need to be monitored closely

Concussion protocol:

Concussion protocol is an organization’s set of policies and procedures for caring for someone who has had a head injury. Even though concussions aren’t limited to sports, concussion protocol is most often associated with sports-related head injuries.

The people involved in making sure the concussion protocol is followed include trained healthcare providers with knowledge of concussion care, athletic trainers, school nurse/counselor/teachers, rehabilitation specialists and parents.

A concussion protocol includes such information as:

Education on concussion definition, signs and symptoms, and management.
Pre-season baseline brain function test (ImPACT test or equivalent) of reaction time, memory, speed of mental processing, and other factors per individual player.
State law criteria for removing a player from activity.
Sideline assessment of the head injury (includes comparison to pre-season ImPACT test or equivalent baseline results).
School adjustments (shorter days, more breaks, extra time to finish assignments, etc.) during recovery.
Gradual return to activity via a gradual process of small increases in activity.

How to Prevent Concussion?

Prevention is better than cure. The risk of concussion can be greatly reduced by taking the following precautions:

• Always wear seatbelts in the car and buckle children in safety seats.
• Drive defensively, not aggressively.
• Eliminate distractions while driving, such as eating, talking on a cell phone, or texting.
• Choose cars with airbags.
• Make sure the airbags in your car are in good working order.
• Wear a helmet that fits when biking, riding a motorcycle, skating, skiing, horseback riding, or playing contact sports. A helmet should be secure and not move when you shake your head, but not be uncomfortably tight.
• Prevent falls on stairs by putting up handrails.
• Install safety gates on stairs to protect young children. Clear your walking areas at home of any objects that might increase the risk of falling, such as loose throw rugs, dropped objects, loose flooring, torn or rumpled carpets, and pet toys or dishes.
• Put grab bars in the bathroom, with nonslip mats in the tub and on floors.
• Improve lighting and remove trip hazards.
• Install safety guards by windows to keep children from falling out.
• Avoid risky behavior in sports: Absolutely avoid football techniques that increase the risk of concussion, such as “spearing” and headbutting. Avoid or limit “heading” the ball in soccer.
• Make sure that all traffic areas in your home are well-lit.
• Avoid exposure to blast explosions and violent events.
• Do not shake babies, or anyone of any age!
• Strengthen your neck muscles. Strong neck muscles may be able to help absorb some of the impact of blows to the head and decrease the risk of concussion.

Physiotherapy Treatment:

How Physio Can Help?

Concussions affect different people in different ways, so your physiotherapist will start by assessing your condition. Often, the injury that causes a concussion may also cause a neck injury. Your physio will assess your neck, as well as your neurological status, balance, and overall function. Based on his or her findings, your physio may use some of the following treatment options to help you feel like yourself again:

• Education
• Manual therapy
• Stretching or strengthening exercises
• Balance and vestibular exercises
• Gradual exertion training
• Progressive return to activity or sport

Concussions are complex injuries and are treated best by a team of different healthcare professionals, especially if your symptoms are slow to recover. Your physio will work closely with the rest of your healthcare team to optimize your recovery so that you can get back to doing what you love.

Treatment may include:

Rest and recovery. Your physical therapist will help you and your family understand why you should limit any kind of activity (daily tasks, work, school, sports, recreation, the use of electronics) after a concussion until it is safe to return to these activities. A period of rest helps the brain heal and helps symptoms clear up as quickly as possible. Your physical therapist will prescribe the rest and recovery program most appropriate for your condition.

Restoring strength and endurance. The physical and mental rest required after a concussion can result in muscle weakness and a decrease in physical endurance. Your physical therapist can help you regain your strength and endurance when the right time comes, without making your concussion symptoms worse. It is common for elite-level athletes and fit “weekend warriors” to experience exercise intolerance with a concussion and brain injury. Your physical therapist will work with you to identify and treat your particular concussion symptoms.

Your physical therapist will design a therapeutic exercise program just for you, and closely monitor your symptoms as you participate in the program.

Stopping dizziness and improving balance. If you have dizziness or difficulty with your balance following a concussion, a type of physical therapy called vestibular physical therapy may help. The vestibular system, which includes the inner ear and its connections with the brain, helps you keep your balance and prevent dizziness. A qualified vestibular physical therapist may be able to help reduce or stop your dizziness or balance problems after a concussion by applying special treatments or teaching you specific exercises, some of which you may be able to do at home.

Reducing headaches. Your physical therapist will assess the different possible causes of your headaches, and use specific treatments and exercises to reduce and eliminate them. Treatment may include stretches, strength and motion exercises, eye exercises, hands-on techniques like specialized massage, and the use of technologies such as electrical stimulation.

Returning to normal activity or sport. As symptoms ease and you are able to regain your normal strength and endurance without symptoms returning, your physical therapist will help you gradually add normal activities back into your daily routine. Your physical therapist will help you avoid overloading the brain and nervous system as you increase your activity level. Overloading the brain during activity after a concussion interferes with the healing of the brain tissue, and can make your symptoms return. Your physical therapist will help you return to your normal life and sports activities in the quickest and safest way possible while allowing your brain to properly heal.

Physical Modalities
Physiotherapists use many passive modalities (electrotherapy, heat, etc.) within their practice to manage the signs and symptoms of concussion. However, as there is currently no evidence to support their use for this patient population, they have not been included at this time. Clinicians are encouraged to use their professional judgment and clinical skill in treatment implementation.

Approach to Treatment: The physiotherapy treatment plan is multifaceted and based on assessment findings and symptom presentation. For example, the timing and intensity of physiotherapy sessions is an integral component of treatment planning for the patient sensitive to external stimuli. Consider scheduling initial appointments when the clinic is quieter/less busy for those with noise sensitivity.

If the patient is sensitive to light, the treatment could occur in a room with curtains drawn or with the patient wearing dark glasses. Increasing exposure to external stimuli and introduction of dual tasking exercises may be incorporated as part of their treatment progression as tolerated. Interventions specific to the patient are prioritized and introduced sequentially to assess response to and confirm the direction of care. For example, depending on the individual patient’s presentation, pain management may be the initial treatment. If assessment findings support a vestibular component, vestibular rehabilitation may be the treatment of choice, but may need to be deferred until the patient’s headaches have been addressed.

Exercises:

Flexion:

Begin with the patient in standing or sitting with the theraband/resistance band anchored at head height behind the patient.
The band should be fixed across the forehead of the patient, a towel may be used under the band for comfort.
Instruct the patient to bring the chin back and lengthen the back of the neck, this should bring about upper cervical flexion and contract the deep neck flexors.
From this position, instruct the patient to nod the head forward while keeping the chin tucked.
Return the head to neutral flexion in a controlled manner. Repeat this action for 8-15 repetitions.

Extension:

Begin with the patient in standing or sitting with the theraband/resistance band anchored at head height in front of the patient.
The band should be fixed across the back of the patient’s head.
Instruct the patient to push backward into the band and then begin to tilt the head back to look upward to the ceiling.
Return to neutral. Repeat this action for 8-15 repetitions.

Side Flexion:

Begin with the patient in standing or sitting with the theraband/resistance band anchored at head height on the contralateral side to the direction of movement.
The band should be fixed across the side of the head ipsilateral to the direction of movement.
Instruct the patient to bring the chin back and lengthen the back of the neck, this should bring about upper cervical flexion and contract the deep neck flexors and reduce any deviation into flexion or extension. Instruct the patient to bring the head to the side as if bringing the ear to the shoulder. Return to neutral. Repeat this action for 8-15 repetitions

Cervical spine issues after a concussion

If the neck or spine has been affected by the concussion an injury, a physiotherapist can help with:

• Strengthening neck muscles
• Manual therapy to ensure the joints are moving well
• Myofascial release techniques to ensure good mobility of the surrounding soft tissue

Vestibular issues after a concussion

Vestibular problems involving dizziness or imbalance can be helped with:

• Balance training
• Canalith repositioning maneuver (a head maneuver to move the ear crystals to an area of your inner ear that eases dizziness)

Visual disturbances after concussion

If vision is affected after a concussion, ocular reflex training can prescribe to improve visual motor control to reduce visual disturbances.

Exertion issues after a concussion

If exertion is a problem, exercise prescriptions should be part of a concussion management plan, with incremental progression of individually tailored exercises.