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.
- 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.
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
- 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.
- 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.
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 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
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 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
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.
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