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Introduction

Concussion is a complex injury that can have far-reaching consequences for an individual, his/her family, and society. Concussion has the potential to be a significant public health burden.

In light of this, concussion management is emerging as a growing practice area in many health-care professions, and research on concussion and its management is evolving rapidly. Research on concussion has primarily been focused on sport-related concussion in children and collegiate athletes. However, concussions can also occur as a result of falls, motor vehicle accidents, explosions and assault, and in conjunction with other injuries. The principles for management of sport-related concussions may be applied to non-sport injuries, and this document will provide guidance as appropriate.

Physiotherapy Alberta - College + Association developed the Concussion Management: A Toolkit for Physiotherapists (the Toolkit) to provide physiotherapists who do not routinely treat concussion with information and resources for evidence-based assessment and management of adult (18+) patients with persistent post-concussive symptoms. Management of pediatric concussion is not included in this Toolkit. Information on the management of pediatric concussion can be found in the ONF Guidelines for Diagnosing and Managing Pediatric Concussion.

Where articles within the Toolkit report research findings in these populations, it is referencing the evidence available to date. The Toolkit is a living document and will be reviewed and revised as knowledge advances.

Originally published in 2016, the Toolkit is based on the recommendations in the 2013 Consensus Statement on Concussion in Sport1 (Consensus Statement) and The 2013 Ontario Neurotrauma Foundation’s Guidelines for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms: Second Edition, for adults (age 18+ years of age)3 (ONF Guidelines).

The toolkit was revised in 2019 to ensure consistency with the 5th International Consensus Statement on Concussion in Sport and the 2018 ONF Guidelines.

Key changes to the document in 2019 include:

  • Updated to the Sport Concussion Assessment Tool 5 (SCAT 5).
  • Updates to risk factors for concussion.
  • Changes to recommendations regarding optimal period of rest.

The text has been supplemented with links to specific modules within the ONF Guidelines. Where possible, this document is aligned with the National Institute of Neurological Disorders and Stroke Common Data Elements for Sport-Related Concussion (NINDS).4

The Toolkit is not a clinical manual; it is intended as a resource for physiotherapists for the provision of evidence-based assessment and treatment of concussion. It provides an overview of concussion (definition, prevalence and prognosis) a review of general concussion management and the physiotherapy role within the multidisciplinary team.

Permission to reproduce in part or whole is granted; please include a printed acknowledgment of Physiotherapy Alberta - College + Association.

 

Concussion

Concussion is a complex pathophysiological process affecting the brain.1 It is the result of a brain injury caused by a biomechanical force such as a direct blow to the head, neck or face, or from a blow to another part the body with a mechanical force transmitted to the head.2 The individual may not experience a loss of consciousness (LOC) with the incident. In fact, only approximately 10% of concussions involve LOC.

Prevalence

Over 160,000 Canadians experience an acquired brain injury annually, with mild traumatic brain injury (mTBI) accounting for the largest proportion of traumatic brain injuries (TBIs).5 Concussion is included in this category as a subset of mild traumatic brain injury. Although the exact incidence of concussion is not known, Statistics Canada reported that 94,000 Canadians aged 12 and over experienced an “activity limiting concussion” between 2009 to 2010.6 The leading causes of concussion were sports, motor vehicle accidents (MVAs), falls, and assault. The majority of these concussions occurred in adolescents and older adults.6

A 2015 report from the Canadian Institute for Health Information found that 27% of brain injuries seen in Ontario and Alberta emergency rooms in the previous year were sport-related, with hockey, cycling and football/rugby leading to the largest numbers of hospital visits.7

In the non-sport population, falls are the leading cause of an mTBI resulting from an external force in adults 65 years and older.8 A cross-sectional study of occupational TBIs in Ontario found that the majority were caused by being “struck by or against an inanimate object” (e.g., falling object, machinery or wall) or by falls, with 57% incurred by men at an average age of 38 years old.9

Signs and symptoms

Signs and symptoms of concussion are believed to be due to a functional disturbance and not a structural injury to the brain.2 Concussion is sometimes referred to as an “invisible injury” as the results of standard structural imaging tests such as MRI or CT scan are normal. However, newer imaging techniques are being developed that may provide further insight into any functional alterations that occur following injury. The Centres for Disease Control and Prevention has categorized the signs and symptoms of concussion into the following four domains:10

Thinking/Remembering Physical Emotional/Mood Sleep disturbance
  • Difficulty thinking clearly
  • Feeling “slowed down”
  • Difficulty concentrating
  • Difficulty remembering new information
  • Headache
  • Nausea or vomiting
  • Balance problems
  • Dizziness
  • Fuzzy or blurry vision
  • Feeling tired, having no energy
  • Sensitivity to light, noise
  • Irritability
  • Sadness
  • More emotional
  • Nervousness or anxiety
  •  Sleeping more than usual
  • Sleeping less than usual
  • Trouble falling asleep

Concussion is suspected if the individual presents with one or more signs or symptoms in any of the above domains. Concussion is diagnosed based on the patient’s symptoms and the findings of a comprehensive, multi-faceted clinical assessment (that considers several of the domains listed above).

The most commonly reported subjective physical complaints following concussion are headache and dizziness, followed by nausea and neck pain.11 Physiotherapy can be effective in cases where symptoms of dizziness, neck pain and headache have a cervical spine and/or vestibular and balance origin.12

Risk of concussion

There are a number of factors, or modifiers, that influence both the risk of concussion and the potential for a prolonged recovery from sport-related concussion. Individuals with a previous history of concussion are at a greater risk of concussion, as are athletes who engage in contact and collision sports. There is also a greater risk of concussion during game play than in practice or training.1

The following factors are suggestive of an increased risk for prolonged recovery in sport-related concussion:

  • Severity of acute and subacute symptoms
  • Subacute signs and symptoms of headache or depression
  • Pre-injury mood or mental health disorders
  • Female, aged 15-17 years of age13

A recent systematic review of prolonged concussion in the non-sport population between the ages of 16 and 65 reported that older age and female gender are the two most significant factors in development of persistent symptoms post-concussion.14

Prognosis

In the majority of sport–related concussion cases, symptoms resolve within seven to ten days from onset. In the non-sport population, most experience full recovery within three months.15

For the remainder, however, signs and symptoms continue beyond this time frame and may persist for months or longer. Up to 30% of children who presented to an emergency room with concussion and head injury report ongoing symptoms one month following mTBI.16 Similarly, symptoms may persist in up to 33% of non-sport-related concussions.17

The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD 10) defines this as post-concussion syndrome with diagnostic criteria including presence of symptoms in three symptom categories four weeks after onset. However, in the literature, the condition is termed “post-concussion syndrome,” “post-concussive syndrome,” “chronic” or “persistent post- concussion syndrome” and “post-traumatic concussion syndrome.” In the current literature, the term persistent post concussion symptoms is most commonly used and will be used in this toolkit.1

The clinical presentation is a set of non-specific symptoms that may be the continuation of symptoms resulting from the original incident, related to secondary injuries (e.g., cervical spine) or to a pre-existing condition such as a migraine headache.15 The differential diagnosis for these symptoms includes depression, somatization, chronic fatigue, chronic pain, cervical injury, vestibular dysfunction, ocular dysfunction, or some combination of these conditions.15 However, it is important to note that there is no one test that can “rule out” a concussion, and some of the symptoms may occur secondary to head trauma. Thus, a careful and systematic differential diagnosis is imperative. Patients whose symptoms persist may also be at risk of co-morbidities such as aerobic de-conditioning, chronic pain, anxiety disorder and depression. Academic or work performance may also be affected.

These signs and symptoms are specific to the individual and treatment should address the clinical assessment findings. The risk for persistent symptoms occurring does not appear to be correlated to the severity of the initial injury.3 Pre-existing conditions may also be factors in the development of ongoing symptoms.15 While the recovery rate for sport-related concussion is high, the incidence of persistent symptoms is higher in those who experience concussions due to other causes.3

Second Impact Syndrome (SIS) is believed to represent an injury sustained over two or more separate events, in which an individual who has had one concussion has a subsequent injury within several weeks of the first, before healing from the initial injury has occurred. This is believed to cause diffuse cerebral swelling, brain herniation, and sudden death.18

Although there are many anecdotal narratives about SIS, it is a controversial diagnosis. Current research suggests that it is a rare occurrence.18 However, it is critical that clinicians reinforce the “recognize and remove” principle and the need for appropriate return to sport measures, including clearance by a health-care professional prior to returning to sport or other activities that include a risk of contact or collision.

Concussion as a co-morbidity

Concussion may occur in conjunction with other injuries. The following are examples of conditions or injuries in which the clinician should consider conducting a scan for concussion:

  • Older adults following a fall
  • Clients presenting with Whiplash Associated Disorder (WAD)
  • Spinal cord injury19
  • Victims of assault
  • Blast injuries (explosions)

If a concussion is a suspected co-morbidity, the physiotherapy assessment for these presenting conditions includes a multidimensional screening tool such as the Sport Concussion Assessment Tool 5 (SCAT5).2 Additional clinical assessment to evaluate the cervical spine and vestibular system as well as a thorough neurological scan should be performed where indicated. If the patient’s clinical history, symptoms and physical exam demonstrate findings consistent with concussion, the physiotherapist has a professional obligation to report these findings to the appropriate health-care providers (e.g., family physician).

Concussion is a functional injury with complex and heterogenous symptoms that may be somatic, cognitive and/or affective in origin. Management will depend on the individual patient presentation and may require a team of health-care professionals who collaborate to provide integrated care (physician, physiotherapist, occupational therapist, speech language pathologist, psychologist, optometrist, etc.). This can be achieved in many ways - from practice co-location to development of a multidisciplinary network.

Initial management

Acute management includes an initial period of 24-48 hours of both cognitive and physical rest immediately following concussion.2, 59 Following this initial period of rest, a gradual return to activities of daily living, followed by a gradual return to school/occupational activities and sport is recommended.2, 59 Individuals do not need to be symptom free to begin returning to activities of daily living; however they need to work at a level that does not provoke or exacerbate their signs and symptoms.59

The Consensus Statement recommends referral for individualized treatment, and multidisciplinary management as appropriate if the individual’s symptoms persist beyond the accepted timeframe of 7-10 days.1 Section 2 of the ONF Guidelines recommends symptom management if symptoms persist more than a few days and referral for comprehensive evaluation and management if symptoms persist greater than four to six weeks.3 Both concur in recommending an initial period of rest to allow the individual’s symptoms to resolve before initiating treatment.

Section 2 of the ONF Guidelines provides recommendations for the initial management of concussion along with printable information sheets for patients and their families. It includes guidance for the patient on care for the first 24-48 hours post-concussion diagnosis, as well as education on signs and symptoms that may occur in the following month.3

Education and reassurance are effective in lowering the risk of prolonged recovery.3 Patients are advised that the prognosis for the majority of individuals is positive. For most individuals, the symptoms are transient and recovery is anticipated within three weeks. Both the patient and his/her family benefit from education about concussion and the importance of appropriate physical and cognitive rest for the initial 24-48 hours following injury.2, 59

Physical rest means avoidance of exercise including activities that increase heart rate, cause the person to sweat or exacerbate concussion symptoms. Patients are encouraged to keep a regular routine that does not provoke their symptoms and to balance daily activity with periods of rest.

Cognitive rest means limiting activities that require focus, concentration and attention and/or increase symptoms. Examples of activities include reading, studying, texting, video game play, television or movies, and use of the computer.20

As concussion is a constellation of heterogenous symptoms, interventions are based on the presenting symptoms and assessment findings for each person and follow a program of gradually increasing both cognitive and physical activity. It is generally accepted that return to school/occupational activities precedes return to sport.1 Gradual increases in both cognitive and physical activity can be planned specific to the occupation/lifestyle of the individual.

For children and youth, the return to learn (full cognitive activity) is managed with a stepwise program, as illustrated in Table 1. Once the student is symptom free for 24 hours, cognitive activity is increased gradually in both complexity and length of time engaged at home and at school. While there is no requirement for medical clearance, once the student returns to school communication with teachers and educators is recommended.

Both the SCAT 5 and CATT tools provide additional information about return to school.

Click to expand.

 

Athletes follow a staged or progressive return to sport protocol. Following a period of 24-48 hours of rest, individuals gradually reintroduce their activities of daily living while staying below activity levels that make their symptoms worse.59 Following this, the individual follows a gradual, stepwise, return to activity and sport which is described in Table 2. If the individual remains asymptomatic for 24 hours at a stage, they progress to the next stage. If symptoms do recur, they are instructed to rest for 24 hours before resuming activity at the level at which they were symptom free. The individual progresses through the stages, only returning to actual (contact or game) play when they have received medical clearance to do so.

Both the SCAT 5 and CATT tools provide additional information about return to sport.

Click to enlarge.

 

Section 12 of the ONF Guidelines provides recommendations for return to work, school and activity for adults following concussion. It includes considerations for post-secondary return to school as well as algorithms for both return-to-school and return-to-work timelines.

Similar to the return-to-learn principles, physical and cognitive activity is gradually increased in focus requirement and complexity while maintaining the sub-symptom threshold. For example, increasing time on an activity, adding external stimuli (sound, busy visual environments) to a task, and resuming computer use, etc.

The effect of the following factors on the individual’s symptoms is included in return-to-work planning:

  • Type of work (physical labour, office work, combination of both)
  • Work environment (open office, driving, home office, amount of interaction with staff or public)
  • Level of stress
  • Mode of transportation (bus, subway, driving a car)

Whenever possible, individuals whose symptoms persist should be referred for further assessment and treatment in a multidisciplinary setting, which may include physiotherapy, depending on the clinical presentation of the individual.

Concussion is a heterogeneous injury and thus can present with a variety of signs and symptoms. Due to this heterogeneity, there are no established, specific protocols for the management of persistent post-concussion symptoms. This is in part due to the range of contributing factors, such as the mechanism of injury (e.g., a non-sport event, a fall, or a motor vehicle collision), pre-existing conditions such as a history of migraine, and the potential for symptom overlap. Section 4 of the ONF Guidelines recommends taking a symptom-based approach as the cluster of symptoms varies considerably between patients.

This means that each person’s management is based on his/her individual clinical presentation.
Similarly, physiotherapy interventions in the management of persistent post-concussion symptoms are based on the physiotherapy differential diagnostic process - a careful assessment of the patient’s history, signs and symptoms.

Physiotherapists are one of the health-care professionals in the multidisciplinary concussion management team, and collaborate with other providers (e.g., physicians, psychologists, occupational therapists) and professionals (educators, employers) in the delivery of optimal care.

Overview

As with other practice areas or techniques (pelvic floor, spinal manipulation), physiotherapists are responsible to develop competence in concussion management and build a network of competent providers for consultation and collaboration as appropriate.

Physiotherapists may screen for concussion, conduct a physiotherapy differential diagnosis of presenting signs and symptoms, and treat those impairments which are responsive to physiotherapy management as well as other presenting co-morbidities. Treatment planning and exercise prescription support the individual’s return-to-play/return-to-activity progression. A comprehensive physiotherapy assessment will also screen for signs of more serious pathology or conditions that may require referral to colleagues with specific expertise or to other disciplines.

Recent research suggests that physiologic (autonomic), cervical and vestibular impairments are potential clinical sub-types or disorders within the concussion diagnosis.21,22,23 As dizziness and headaches may be reported in a physiologic disorder following concussion, as well as in cervical and vestibular disorders, physiotherapy assessment can help differentiate the origin of these symptoms and determine the appropriate management strategy.24

The following sections provide information on:

  • Screening tools used to assist in the assessment of concussion
  • The approach to assessment of an individual with concussion or persistent symptoms, with links to tools referenced
  • Current evidence for physiotherapy management of concussion

The Toolkit is not a clinical manual; it is intended as a resource for physiotherapists in the provision of evidence-based assessment and treatment of concussion. Physiotherapy assessment will include documentation of signs and symptoms of mood disorder, cognitive symptoms and sleep disturbance, although the Toolkit does not include management strategies for these symptoms. Physiotherapists are advised to be aware of these aspects, consider the implications to their practice, and when appropriate, refer to the appropriate clinician.

Sections 7, 8, and 9 of the ONF Guidelines review management of persistent sleep-wake disturbances, mental health and cognitive disorders.

There is evidence that neuropsychological testing can be a useful aid in management of concussion in conjunction with other assessment tools and clinical judgment. The tests are best administered and interpreted by a neuropsychologist and will contribute to the medical decision regarding return to play. However, there is insufficient evidence to support the routine use of baseline neuropsychological testing.1

Two currently available screening tools help guide the clinician in determining whether the patient has sustained a concussion: the Sport Concussion Assessment Tool – 5 (SCAT5)2 and the Vestibular/Ocular Motor Screening Assessment (VOMS).25,61 The two tools are complementary and help determine the best course of treatment. The SCAT5 documents signs and symptoms, while the VOMS screens for vestibular and ocular motor impairment and symptoms.

SCAT5

The SCAT5 (Appendix 1) is a standardized tool designed for use by multiple different health-care professionals in the assessment of concussion in individuals 13 years of age and older. It includes validated assessment tools for both signs and symptoms of concussion and can be used as a screening tool to rapidly evaluate domains such as symptoms, immediate and delayed memory, concentration, coordination and standing balance. It takes approximately 10-15 minutes to complete.

The SCAT5 and its components, particularly the symptom scale, may be used throughout treatment to monitor the patient/client’s progress and provides a consistent reporting mechanism for use across disciplines. However, the ability of the SCAT5 to screen for concussions diminishes after the first 3-5 days post-injury. The tool should not be used to screen for a concussion beyond the initial 3-5 days post injury. The SCAT5 is not intended for use to “clear” an athlete for return to sport.

This tool was developed in the area of sport-related concussion but may also be used in the area of non- sport concussion, although this has not yet been evaluated in the literature.

While it is understood that the SCAT5 has limitations, it is a concise tool that covers multiple domains and is used by several professions. This facilitates communication between professionals and supports quality care.

The SCAT5 post concussion symptom scale may be completed by the patient or with assistance (i.e., with family member or through a clinician interview). In either case, the process used to complete the symptom scale should be recorded as this can affect the scoring.

Note: The Maddox score in SCAT5 is used in the on-field assessment only.

The SCAT5 includes a modified Balance Error Scoring System (mBESS). However, the BESS itself has not yet been validated for use with non-sport concussions, and performance has been shown to decrease when the subjects are over 50 years of age.26

The Single Limb Stance Test (SLS) or Unipedal Stance Test is part of the BESS and has been tested for use with a range of conditions, including concussion for individuals from ages 18-99. Normative values for test results for each 10-year age grouping have been reported.27

Vestibular Ocular Motor Screen (VOMS)

The VOMS (Appendix 2) was first published in 2014 and has been proposed as a brief clinical screen for detection of concussion in the subacute time period following concussion (2-10 days) in adults with sport-related concussion under the age of 49. It has been reported to identify change in symptoms related to oculomotor and vestibulo-ocular stimuli. The mBESS and the VOMS are complementary screening tools. The mBESS assesses standing balance in different stances on a firm surface, and the VOMS includes a series of vestibular and oculomotor tests that are completed by the patient. The VOMS is not used to evaluate the patient’s ability to complete the tests, but rather examines the effect each test has on his/ her symptoms.

A video produced by the University of Pittsburgh Medical Centre demonstrates its application here: https://www. youtube.com/watch?v=E2uF0lcyNps.

While the SCAT5 and VOMS screen for signs and symptoms related to concussion, they are not stand-alone assessments. Incorporating multiple tools helps ensure a comprehensive assessment. The two screening tools are used to provide relevant information in the differential diagnosis process. A thoughtful history and clinical examination as well as engagement of the physician and other health-care professionals based on the patient presentation is imperative for management of persistent post-concussion symptoms.

When it has been verified that the clinical presentation is consistent with concussion, a detailed assessment is conducted to determine whether physiotherapy is indicated for the individual.

Physiotherapy can be effective in concussion management when dizziness, neck pain, headache and impaired balance have cervical spine and/or vestibular involvement. Treatment is based on the physiotherapy differential diagnosis made through patient history and clinical assessment of presenting signs and symptoms.

A Differential Diagnosis Checklist has been included as Appendix 3.

The history, screening tools and initial physical scan are the first step in differentiating potential symptom origins.

A.    History

  • Mechanism of injury
  • Current symptom intensity/frequency in comparison to pre-injury status
  • General medical history: determine any pre-existing conditions that may affect symptoms and recovery. Include:
    • Age and gender
    • Prior concussion history
    • History of migraines, sleep disorders, depression, ADHD, etc.
  • Occupation/employment: determine normal level of physical/cognitive activity in planning return to sport/work/school/play
  • Other activities: determine levels of activity to monitor during rehab process such as driving, sports, writing, music, social media, etc.
  • Mood: the symptom severity questionnaire in the SCAT5 includes four questions on mood
  • Sleep pattern: any indication of disruption to normal sleep pattern (drowsiness, falling asleep or difficulty waking)

Identify the other members of the interprofessional health-care team. Refer the patient to his/her physician, a clinical psychologist or neuropsychologist if there are any indications that either mood or sleep has been affected since the injury occurred. Occupational therapy may also be indicated in management of fatigue.

B.    Medical tests and results

Physiotherapy assessment includes documentation of the following:

  • Physician/medical investigation, including any record of tests ordered in the diagnostic process
  • Radiological/diagnostic imaging results, where indicated (see below)
  • All medications including the type (prescription or OTC) and frequency /pattern of use to determine compliance or overuse.

Red/Yellow flags

The following signs and symptoms may be indicators of cervical spine fracture, subdural hematoma, or cerebral bleed. Refer the patient for immediate medical evaluation if there is evidence of the following:

  • Diplopia, dysarthria, dysphagia, quadrilateral paresthesia/numbness
  • Significant mid-line cervical spine tenderness
  • Fainting or loss of consciousness
  • Progressively worsening headache
  • Confusion
  • Repetitive vomiting

In some patients, evaluation with the Canadian c-spine rule28 may be appropriate. It is a useful screening procedure that assists the clinician in determining the need for diagnostic imaging in the alert patient who has neck pain following blunt trauma. Therapists may apply it as part of their assessment of patients demonstrating red/yellow flags.

These two videos illustrate how the C-spine rule is used in hospitals and how it can be used in a physiotherapist practice:

C.    Physical scan

Clinical assessment begins with tools that are least likely to provoke symptoms and progresses to those more likely to do so.

Initial scan:

  • Observation of posture in:
    • Standing, sitting and walking, including head position in all three postures
  • Neurologic scan, which includes:
    • Cranial nerves
    • Dermatomes and myotomes (key muscles)
    • Deep tendon reflexes (upper and lower extremities)
    • Cerebellar function
    • Upper motor neuron (e.g., clonus, Babinski, Oppenheimer and Hoffman’s)
  • Resting heart rate, blood pressure.

A useful review of the neurological clinical assessment can be found at Neuroexam.com.

Based on the initial findings, a detailed assessment is performed to gather and incorporate new information and to further clarify the most likely cause of presenting signs and symptoms, whether cervicogenic, vestibular, or other. Assessment findings will help determine the priorities in treatment planning and implementation.

Clinical Tip: The findings of the neurological scan will help determine sequence and direction of assessment.

Cervical Spine

Cervicogenic signs and symptoms may include neck pain, dizziness, headache and difficulty with balance or unsteadiness. Several of these symptoms are similar to, or overlap with, other headache subtypes, vestibular signs and symptoms in concussion or persistent post-concussive symptoms.3

It is important to differentiate signs and symptoms originating from the cervical spine from the vestibular signs and symptoms in concussion or post-concussive symptoms.

A neurological scan and assessment of the cervical spine are conducted prior to vestibular assessment. This will ensure that the individual’s cervical spine can tolerate the positions and movements required for vestibular testing (e.g., extension and rotation). Assessment begins with active range of motion, passive ROM and palpation of the cervical spine.

Cervical assessment includes a cervical scan and preliminary biomechanical assessment of the cervical and upper thoracic spine. In the event of positive findings, such as symptom provocation or alleviation, a more detailed assessment of the appropriate level(s), is carried out. Physiotherapists who do not routinely use manual therapy in their practice may consult a physiotherapist who routinely uses these skills.

The cervical assessment includes a test for vertebrobasilar insufficiency (VBI). VBI is a medical condition caused by a disruption in the vertebrobasilar arterial system. It is not common, but is a serious condition that causes dizziness, and requires the physiotherapist to rule it out in assessment. If any alerting factors in the neurological scan or history suggest VBI, the patient should be referred to his/her physician. Current best practice is to perform the modified Vertebral Artery Test (mVAT), an active test carried out in sitting, prior to treating the cervical spine.

There is some debate on the validity of the mVAT as a test for VBI.31 In the event of a positive finding or suspected VBI, refer the patient to his/her physician for further assessment or for urgent medical care as indicated.

The Cervical Joint Position Error Test (JPET) is believed to assess cervico-cephalic proprioception and neck reposition sense.33 It is easy to administer and tests the patient’s ability to relocate his/her head back to center after maximal or submaximal rotation in the transverse and sagittal planes.

Physiopedia’s Cervical Scan and the International Federation of Orthopaedic Manipulative Therapists’ Cervical Framework Document provide useful reviews for physiotherapy assessment of the cervical spine. Links to these websites can be found in the Resources section.

*In the case of cervical spine involvement, positional tests for the vestibular system can be performed with the cervical spine in neutral to identify the source of signs and symptoms.

CLINICAL TIP: Begin VBI testing in least provocative position and progress. As part of the differential diagnosis process, consider the possibility of vestibular involvement, and rule this out using the approach detailed in the APA Clinical Guide to Safe Manual Therapy Practice in the Cervical Spine (Part 1): Vascular Considerations (Appendix 4).32

Assessment - specific symptoms

Based on history and findings, the assessment will focus on specific symptoms. The following assessment tools do not represent all testing procedures but were selected based on evidence for their use in each symptom presentation.

Headaches

Headaches are consistently the most common symptom reported following concussion. For the patient with persistent post-concussion symptoms, however, there may be other causes.

Headaches are differentiated as primary (diagnoses such as migraine, tension or cluster) and secondary (headaches arising from other causes, such as sinus, cervicogenic, trauma or meningitis).34 The diagnostic criteria for cervicogenic headache includes headache with neck pain and stiffness, and dysfunction in the upper cervical spine.40

Symptoms of cervicogenic headache may originate from dysfunction in the upper cervical spine (levels C0-C3.29,30 Cervical facet joints, muscles and/or nerve roots may also be the source of pain.

Research supports physiotherapy as an intervention for the assessment and management of primary chronic tension-type headaches35 and secondary headaches of musculoskeletal origin, such as the cervicogenic headache.36,37

There is no evidence that physiotherapy is effective in the management of other headaches, such as migraine. If signs and symptoms are indicative of migraine, the patient is referred to his/her physician.

Section 6 of the ONF Guidelines provides an overview for the management of post-traumatic headaches.

The Headache Impact Test (HIT-6TM)38 is a self-report questionnaire that can be used on initial assessment and to monitor change or progress during treatment. The six questions measure the impact of headaches on the individual’s normal function at work, school, home and in social situations. It uses a five-point scale and scores over 50 indicate the need for medical attention.

The Cervical Flexion Rotation Test has been validated as an assessment tool for cervicogenic headaches (CGH).39 Rotation is significantly reduced in patients with CGH compared to other headaches and the asymptomatic population.39

The Cranio Cervical Flexion Test is used to assess the ability to recruit the deep cervical muscles during craniocervical motion. Impairment or delayed action of the deep cervical muscles may be a factor in headaches.41

Dizziness

Prolonged dizziness following concussion may occur for a variety of reasons. The cervical spine and the vestibular system are two potential sources, although a range of other systems may be involved (e.g., postural hypotension, infections, or vertebrobasilar insufficiency, etc.).31 Assessment of dizziness integrates all clinical findings (e.g., cranial nerves, cervical spine assessment) with the history to differentiate the most likely source of symptoms and determine if physiotherapy interventions are appropriate, or if further medical evaluation is warranted.

The Dizziness Handicap Inventory (DHI) is a 25-item self-assessment inventory used to evaluate the perceived handicapping effects imposed by dizziness and can be used to monitor treatment effectiveness.42 Each item is scored as: 0 (representing none), 2 (somewhat) or 4 (yes).

CLINICAL TIP: Record the nature, duration of dizziness, and aggravating and easing factors. Clarify whether the patient has previously experienced or currently experiences vertigo, which will help differentiate the source and assist in the assessment and treatment planning.

Vestibular System

Vestibular dysfunction may affect balance, posture or vestibulo-ocular function. In the case of cervical spine involvement, positional tests for the vestibular system can be performed with the cervical spine in neutral to identify the source of signs and symptoms. The BESS, described earlier, assesses standing balance. The vestibulo-ocular reflex (VOR) is responsible for maintaining focus on a target while the head is in motion. Depending on assessment findings, a more detailed vestibular assessment may be indicated. In the case of suspected central vestibular dysfunction, phyiotherapists who do not have that skill set should refer their patients to their physician for further medical evaluation or a physiotherapist with expertise in vestibular rehabilitation.

Benign Paroxysmal Positional Vertigo (BPPV) is a mechanical problem with the inner ear that results in episodes (seconds) of vertigo with changes in position. There is evidence that five of the items included in the Dizziness Handicap Inventory (numbers 1, 5, 11, 13 and 25) form a subset helpful in determining if the patient has BPPV. Positive responses to all five, along with history and assessment findings, help guide the direction of the assessment and may indicate referral to a vestibular therapist for management of BPPV.43

In the senior population, there is evidence that a DHI score greater than 50 may be a predictor of BPPV, again informing the assessment process and/or indicating referral to a vestibular therapist.44

Balance

Observe the individual’s response to static and dynamic tests, dynamic functional activities (such as sit to stand), and a range of gait patterns (e.g., tandem gait, heel/toe, forwards/ backwards). Although generalized balance testing is not specific to vestibular dysfunction, in the case of vestibular dysfunction, individuals may have difficulty when testing requires them to rely on vestibular input to maintain balance (e.g., standing with eyes closed, turning head while walking).

Section 10 of the ONF Guidelines provides an overview of the assessment and management of persistent vestibular (balance and dizziness) and vision dysfunction in mTBI.

Further information on balance, dizziness and vestibular disorders is available from the Vestibular Disorders Association.

Additional tests

The following tests may be useful in the assessment of dynamic balance, depending on the patient’s age, medical condition or other factors (e.g., activity level):

The Functional Gait Assessment45 was developed based on the Dynamic Gait Index, and has been validated for community dwelling adults between the ages or 40-89 and for those with neurological conditions including TBI and vestibular disorders. Along with the BESS, it may be useful in assessing balance and postural control in concussion management in all populations.46

The Dynamic Gait Index45 is used among older adults with functional limitations due to chronic conditions. It is designed to allow for use of an assistive device.

The Community Balance and Mobility Scale was developed for use with adults with mild to moderate neurological deficits, including traumatic brain injury in a variety of settings from acute care to the community.47

An individualized approach to treatment is recommended for individuals who have ongoing symptoms following concussion. The 5th International Consensus Statement recommends referral to a multidisciplinary team for management if the individual’s symptoms persist beyond the accepted timeframe. Module 2 of the ONF Guidelines recommends symptom management if symptoms persist for more than a few days and referral for comprehensive evaluation and management if symptoms persist longer than four to six weeks. Both concur in recommending an initial period of rest (24-48 hours) to allow the individual’s symptoms to resolve before initiating active treatment.

Active rehabilitation is recommended to minimize risk of adverse physical or psychological consequences or prolonging symptoms.48

Section 5 of the ONF Guidelines describes general management of persistent symptoms following concussion.

At time of writing, there are no evidence-based guidelines for physiotherapy specific to management of persistent post-concussion symptoms. Physiotherapy treatment is therefore based on clinical assessment of signs and symptoms and implementation of existing evidence-informed interventions for the identified impairments.49

The research on rehabilitation for persistent post-concussion symptoms is primarily in the context of sport-related concussions and for children and collegiate athletes. While these research findings have not been evaluated for adults with non-sport related concussion, the principles may be applied to their treatment within the context of the individual’s age, goals and function.

Physiotherapy management includes education and support, and treatment of signs and symptoms responsive to physiotherapy. Research supports the use of individualized cervical and vestibular interventions, and there is emerging evidence that sub-symptom threshold exercise may be of benefit.59

Cervicogenic and vestibular management

A recent RCT showed that adolescents and young adults with persistent symptoms following concussion who were
treated with physiotherapy interventions (including treatment for cervical and vestibular findings such as neuromotor retraining, sensorimotor retraining, manual therapy and vestibular rehabilitation) were nearly four times more likely to be medically cleared to return to sport in an eight-week time-period when compared to rest and the standard return-to-play protocol.12,60

Cervical spine rehabilitation

Physiotherapy interventions for cervicogenic impairments may include neuromotor retraining (for the craniovertebral and cervical and scapulothoracic regions), sensorimotor retraining, manual therapy and soft tissue techniques.

Vestibular rehabilitation

Vestibular rehabilitation has been shown to be effective in the management of dizziness and gait and balance dysfunction following concussion in both children and adults.50 Techniques may include adaptation, substitution, habituation, standing and dynamic balance retraining, and canalith repositioning maneouvers.

Aerobic exercise

Exercise intolerance may be a physiologic sign of concussion. However, the current evidence is limited to uncontrolled studies and the improvements seen may be due to time or other factors.52 Recent studies have demonstrated that sub-threshold aerobic exercise is safe and may improve symptoms and outcomes in patients with persistent symptoms, as well as improve fitness and autonomic function (i.e., better heart rate and blood pressure control) during exercise in both the sport and non-sport concussion populations.53,54,55 Symptom threshold may be established with exercise bicycle or treadmill testing. Similar protocols have demonstrated functional improvements in children.56 Patients should be monitored for symptom exacerbations during and following exercise.

Activity pacing

Many clinicians include pacing and planning daily activity within the multidisciplinary plan of care for individuals with persistent post-concussive symptoms.3 Learning to use strategies (e.g., using a daily planner, a timer to limit participation, and planned rest times) to keep symptoms sub-threshold in daily activities is thought to support a gradual increase in tolerance and rehabilitation goals. Where possible, an occupational therapist should be consulted to provide guidance on planning and pacing daily activities.

The Pain Health website (A Government of Western Australia Department of Health initiative) provides individuals who have chronic musculoskeletal pain with evidence-informed information and resources for management of their pain. It describes strategies and provides worksheets to help establish their symptom sub-threshold target and remain symptom free while gradually increasing activity levels.

Oculomotor dysfunction

There is evidence that up to 30% of athletes experience visual disturbances in the first week following injury.57 If these symptoms persist (e.g., blurred vision, reading problems, diplopia, vestibular symptoms in crowded environment, light sensitivity) there may be a detrimental effect on the individual’s recovery.58 Based on clinical exam findings, a referral to a vestibular therapist, a neurologist, a neuro-optometrist, or to their physician for management may be warranted.

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 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.24

WHAT WE KNOW: Concussion is a functional disturbance of the brain with a complex and heterogeneous symptom presentation. It should be managed based on the individual’s presentation. A period of 24-48 hours of physical and cognitive rest should be performed following a concussion. After this point, a gradual return to activities of daily living should ensue prior to a gradual return to school or occupation. A return to sport strategy may occur simultaneously with return to school or occupation, however full return to school or occupation should occur prior to full return to sport. In the case of ongoing symptoms of dizziness, neck pain and headaches for greater than 10 days, multimodal physiotherapy (including treatment for the cervical spine and vestibular systems) may be of benefit.

EMERGING EVIDENCE: Symptom-limited aerobic exercise, a collaborative approach to care and use of a psychologically informed approach (i.e., cognitive behavioural therapy) may be of benefit in the treatment of concussion, however the current evidence is limited.

WHAT WE DON’T KNOW: The optimal duration of rest and timing of initial treatment following injury is not yet fully understood.57

TAKE AWAY MESSAGE: Concussion is a complex and heterogenous injury with symptoms that may be somatic, cognitive and/or affective in origin. Treatment is based on the individual patient’s presentation. Physiotherapy may be of benefit but should be provided in the context of an interdisciplinary team approach whenever possible.

Although the majority of individuals who experience a concussion have a full recovery, as many as one third will report persistent symptoms for an extended period of time.

These individuals benefit from careful assessment, and a multidisciplinary approach to care when possible. Physiotherapy is indicated and can be effective in concussion management where the origin of the symptoms of dizziness, neck pain, headache and impaired balance have a cervical spine and/or vestibular origin.

Physiotherapy Alberta developed this Toolkit to provide physiotherapists with information and resources for a consistent approach to management of adults who have sustained a concussion.

It is critical that physiotherapists recognize the complex and multifaceted nature of concussion and understand their role and context within a multidisciplinary management approach.

Physiotherapists have the knowledge and skill to assess and treat the relevant impairments (cervical and vestibular) related to concussion and persistent symptoms, and to provide insight into the potential origin of symptoms that can help determine the appropriate course of treatment.

Concussion is a functional brain injury with complex and heterogeneous symptom presentation. Physiotherapy is indicated and can be effective in concussion management where the symptoms of dizziness, neck pain, headache and impaired balance have cervical spine and/or vestibular involvement. Treatment is based on the physiotherapy differential diagnosis made through patient history and clinical assessment of presenting signs and symptoms.

Red/Yellow Flags

The following signs and symptoms may be indicators of serious pathology, such as cervical spine fracture, subdural hematoma, cerebral bleed or brainstem ischemia. Refer the patient for immediate medical evaluation if there is evidence of the following:

  • Diplopia, dysarthria, dysphagia, quadrilateral paresthesia/numbness

  • Significant mid-line cervical spine tenderness

  • Fainting or loss of consciousness

  • Progressively worsening headache

  • Confusion

  • Repeated vomiting

Click to enlarge.

 

* Adapted from Centres for Disease Control and Prevention four domains of concussion.

Online Resources Concussion Management

Awareness, Education, Management

Pediatric Concussion Management

Cervical Spine Assessment

Vestibular Disorders

Managing Chronic Pain

Additional Reading

Concussion Management

  • Matuszak JM, McVige J, McPherson J, Willer B and Leddy JJ. A Practical Concussion Physical Examination Toolbox:Evidence- Based Physical Examination for Concussion, Sports Health: A Multidisciplinary Approach 1941738116641394. Published online before print March 28, 2016, doi: 10.1177/1941738116641394
  • Marshall S, Bayley M, McCullagh S, Velikonja D, Berrigan L, Ouchterlony D and Weegar K, Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms, Brain Injury 2015 29:6, 688-700. http:// doi.dx.org/10.3109/02699052.2015.1004755
  • Broglio SP, Collins MW, Williams RM, Mucha A and Kontos AP, Current and Emerging Rehabilitation for Concussion: A Review of the Evidence, Clin Sports Med 2015 34, 213-231
  • Valovich-McLeod T C and Hale TD Vestibular and Balance Issues in Sport Related Concussions, 2015 Brain Injury 29:2, 175-184 http://doi.dx.org/10.3019/02699052.2014.956206
  • Leddy JJ, Baker JG, Merchant A, Picano J, Gaile D, Matuszak J, and Willer B Brain or Strain? Symptoms Alone Do Not Distinguish Physiologic Concussion from Cervical/Vestibular Injury Clin J Sport Med vol 0 number 0 month 2014
  • Carson JD, Lawrence DW, Kraft SA, Garel A, Snow CL, Chatterjee A, Libfield P, MacKenzie H M, Thornton, JS, Moineddin M and Fremont P, Premature Return to Play and Return to Learn after a Sport-Related Concussion. Physician’s Chart Review 2014 Can Fam Physician 60:e 310-5
  • Koslowski KF, Graham J, Leddy JJ, Devinney-Boymel D, and Willer BS, Exercise Intolerance in Individuals with Post-Concussion Syndrome, Journal of Athletic Training 2013;48(5):627-635 doi:10.4085/1062-6050-48.5.02
  • Stewart GW, McQueen- Borden E, Bell A, BarrT, and Juenling J, Comprehensive Assessment and Management of Athletes with Sport Concussion Int J Sports Phys Ther 2012 Aug 2012 (7)4: 443-447
  • Vidal PG, Goodman AM, Colin A, Leddy JJ, and Grady MF Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent Populations 2012 Pediatric Annals 41:9 http://concussion.ubmd.com/wp-content/ uploads/2014/04/4109Rehabilitation.pdf
  • Laker SR, Epidemiology of Concussion and Mild Traumatic Brain Injury PM R. 2011 Oct;3(10 Suppl 2):S354-8. doi: 10.1016/j. pmrj.2011.07.017.

Physiotherapy Management

  • Schneider, KJ Sport-Related Concussion: Optimizing Treatment Through Evidence-Informed Practice J Orthop Sports Phys Ther 2016;46(8):613–616. doi:10.2519/jospt.2016.0607
  • Hugentobler JA, Vegh M, Janiszewski B, Quatman-Yates C Physical Therapy Intervention Strategies for Patients with Prolonged Mild Traumatic Brain Injury: Case Series Int J Sports Phys Ther. 2015 Oct;10(5):676-89.

Cervicogenic Dizziness

  • Reid SA, Callister R, Katekar MG, Rivett D. Effects of cervical spine manual therapy on range of motion, head repositioning, and balance in participants with cervicogenic dizziness: a randomized controlled trial, Arch Phys Med Rehabil. 2014 Sep;95(9):1603-12. doi: 10.1016/j.apmr.2014.04.009. Epub 2014 May 2.
  • Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett D. Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial. Man Ther. 2015 Feb;20(1):148-56. doi:10.1016/j.math.2014.08.003. Epub 2014 Aug 27.

Cervicogenic Headache

  • Page P Cervicogenic Headaches: An evidence-led Approach to Clinical Management: Clinical Suggestion Int J Sports Phys Ther 2011, Sept, 6(3) 264-266.

Vestibular Symptoms

  • Alsalaheen, BA,, Mucha A, Morris LO, Whitney SA et al Vestibular Rehabilitation for Balance and Dizziness Disorders After Concussion, JNPT, vol 34 June 2010

Oculomotor Symptoms

  • Ciuffreda KJ and Kapoor N, Oculomotor Dysfunctions, their Remediation and Reading-Related Problems in Mild Traumatic Brain Injury, Journal of Behavioural Optometry, 2007, vol18, no 3, 72-77
  • Barnett BP and Singman EL, Vision Concerns after Mild Traumatic Brain Injury, Curr Treat Options Neurol (2015) 17:5 doi 10.1007/s11940-014-0329-y

Concussion Management: a Toolkit for Physiotherapists was developed by Physiotherapy Alberta - College + Association with the following working group members. Their considerable knowledge, expertise and commitment were essential to the content and quality of the document:

Project team

  • Kathryn Schneider PT, PhD, Dip Manip PT, DSc, Certificate in Vestibular Rehabilitation, CGIMS, Clinical Specialist - Musculoskeletal Physiotherapy, Evidence Sport and Spinal Therapy, Assistant Professor, Clinician Scientist, Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, member Alberta Children’s Hospital Research Institute for Child and Maternal Health and the Hotchkiss Brain Institute
  • Codi Isaac PT, MSc PT, B Com, Sport Physiotherapy (Cert), Certificate Vestibular Rehabilitation, Isaac Physiotherapy – a Concussion Health Certified Centre, Edmonton AB
  • Catherine Ross PT, BScPT, Certificate Vestibular Rehabilitation, FCAMPT, Gunn IMS, Clinic Director, Lifemark Physiotherapy, Lake Beaumaris AB
  • Project lead: Carol Miller PT, Knowledge Mobilization, Physiotherapy Alberta

External reviewers

In addition, Physiotherapy Alberta thanks the following individuals for their review of the draft document. Their contribution and recommendations were essential to the final project outcome.

  • Carolyn Emery PT PhD, Associate Dean (Research) Faculty of Kinesiology, University of Calgary, Chair Sport Injury Prevention Research Centre and Chair Pediatric Rehabilitation, University of Calgary.
  • Martin Mrazik, BSc, BEd, MEd, PhD, R.Psych, Associate Professor, Department of Educational Psychology, University of Alberta.
  • Bernard Tonks PT BSc PT, FCAMPT, Director, Balance and Dizziness Rehabilitation Clinic, Vancouver BC
  • Carol Kennedy PT BScPT, MClSc(manipulation), FCAMPT, Clinical Specialist, Musculoskeletal Physiotherapy, Treloar Physiotherapy, Vancouver BC
  • Jacqueline van lerssel PT PhD(c), MSc, BScPT, BPE, FCAMPT, SPC Diploma, CAFCI, CSCS, R2P Concussion ManagementTM, Ottawa ON

Permissions

Materials from The Ontario Neurotrauma Foundation, The Physiotherapy Association of British Columbia and Dr. Ian Stiell, Ottawa Hospital Research Institute, were incorporated in the Toolkit with permission.

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