The Role of Physiotherapy in Concussion: A Slightly Deeper Dive

Many have experienced a concussion after a motor vehicle accident or, typically, during a rugby game. Normally, people would be rushed to the hospital and told to rest for a minimum of 48 hours to allow the brain to heal. But have you ever thought about what else could have been impacted by this event?

To understand how to manage a concussion, we have to understand what actually "goes wrong" in the body and brain. Essentially, a concussion is an injury to the brain at the cellular level (that's why scan results come back as normal). Injury to the brain causes a metabolic cascade of events including:

Generally, the Sympathetic Nervous System (Fight-or-Flight mode) helps keep the body's systems within a 'normal' range, called homeostasis. When the above bullet points occur, your body needs to work harder to maintain homeostasis, which can result in the body 'running on fumes' because the system is not getting the support it needs from the brain to recover. This is when Dysautonomia occurs. Dysautonomia is when the brain's ability to perform various functions is compromised. Another thing that occurs is the blockage of the Parasympathetic Nervous System (Rest and Digest mode). In essence, you stay in fight-or-flight mode. In addition to that, you've got cell death, glucose deprivation, and inflammation in the brain. In theory, this lasts for 10-21 days. In reality, the research suggests that this can last 3-6 months.

So we need to find out exactly what has been damaged. And if its damaged, we need to be able to work on strategies to fix it and prevent persistent symptoms. Symptoms will be in any of the bodily systems that are affected. Therefore, we look at the pattern and what we're looking at is, functionally, with these symptoms, where are they unable to perform. This gives us the ability to identify how severely they have been affected. So, we have to know what to look for in which system.

Typical recovery and initial management of concussion is cognitive and physical rest for 24-48 hours.

The Golden Rule is to rest the brain and exercise the body. For the younger population, earlier commencement of movement results in quicker recovery. This can be achieved by selecting the level of activity that the patient can do. When a patient is experiencing severe dysautonomia, exertion is going to flip the blood supply and flip the Autonomic Nervous System, and they crash. We have to be extremely careful to ensure we stay within a safe equilibrium, while also not limiting a system that is not affected.  

Factors that affect concussion recovery

• Effects of sleep dysfunction such as insomnia, working night shift, or history of migraines linked to insomnia, result in patients already starting on the back foot of the recovery scale. There is a mismatch because there are too many people who are wired and tired, meaning that they have the sympathetic drive without fuel, block the parasympathetic system, and are unable to relax and allow the body to recover. If this mismatch is not balanced, rehabilitation will not be effective.

• Gender differences play a role in the recovery process: Females report more systems than males; females report neurobehavioral and somatic issues whereas males report cognitive challenges. Females over 35 (perimenopausal, menopause) take longer to recover. The impact of aging on recovery is that concussion often goes undiagnosed, as we assume that the cognitive deficits are age-related. Therefore, it is of utmost importance to listen to patients, to their stories. Risks of falls include sarcopenia, lack of activity, and a sedentary lifestyle resulting in a vicious cycle of decreased movement, which leads to falling, which leads to the development of a fear of falling. In relation to aging, we also need to consider medication and its side effects to prevent falling and entry to the vicious cycle.

In the younger population, there is often a mismatch between patient and parental expectation. An example of this would be 'underplaying or catastrophizing' systems leading to mental health issues, making room for behavioural outbursts.

Interestingly, Benign Paroxysmal Positional Vertigo (BPPV) is common in older adults, and you don't need to report dizziness to experience BBPV. Vestibular Hyponisia occurs where people have gotten so accustomed to it that they no longer recognise the dizziness.

We have to keep in mind that if patients are not successfully treated and managed, they are going to have unknown problems. Again, concussions are heterogenous and involve different systems

• Concussions exacerbate pre-existing conditions. 

  Concussions have a way of highlighting previous challenges as the brain is no longer able to 'correct' and compensate for the dysfunction. An example of this would be: if a patient wears or used to wear spectacles and had a lazy eye- now, they are unable to compensate. The same concept applies if a patient was successfully managed in a vestibular challenge. The brain was able to compensate for the changes or losses but after a concussion, the brain loses its ability to do that. 

• Neurodivergence is a significant factor with concussion as it is a neurological condition in itself. This is sometimes the case with migraines or history of trauma. Their brains wiring, coping mechanism, and in essence Autonomic Nervous System is going to be different. 

What Can Physiotherapists do to help?

The Neurosensory Assessment consists of co-morbidities and history of previous injury. This includes previous concussion, journey to recovery, and the use of questionnaires. This is done because people often do not recognise oculomotor issues due to self-selected adaptation to activities such as watching TV. When recovery is prolonged, anxiety, frustration and depression may make an appearance. Therefore, the expectation of initial assessment will be low with patients who present with a high symptom load.

It would be sufficient to obtain history and do questionnaires so that the patients' protective walls / compensatory mechanism does not go into overdrive. Here, you can observe that the patient is hesitant with their speech and struggles with word finding. By doing this, unmanaged dysautonomia and assessment of the oculomotor system will result in the patient shutting down.

For patients with no or low symptom load, we have to identify which system is affected and address the sympathetic drive with reassurance, education and learning strategies to decrease the sympathetic nervous system drive.

An interesting fact is that 70% of the brain is dedicated in some way or another to vision. We absolutely cannot skip the oculomotor assessment. It just needs to be addressed at a later stage.

Essential Physiotherapy assessments for patients with concussion:

During the oculomotor assessment, we are looking for:

• Fixation

• Points of focus from near to far

• Mechanics of the eyes moving 

• Mechanics of the eyes jumping 

Also looking at the 2nd, 3rd, 4th and 6th cranial nerves (Possible, age-appropriate reading assessment because the whole brain is working), listen for:

• Staccato 

• Reading 

• Hesitancy 

• Get lost before finding the next line at the end of the previous line

• Get overwhelmed by all the words 

During the vestibular assessment, first rule in/out BPPV, then, look for:

• Gaze stability (Is the patient able to spot where they're escaping to while they're running to escape the line)

• Looking to see: Head movement with target fixation

The vestibular system plays an enormous role in the fight-or-flight response, therefore, jumping into vestibular rehabilitation reinforces sympathetic drive.

During the balance assessment, we look for:

• Static and dynamic balance 

• In the younger population, dual tasking 

• Cognitive challenging

Be sure to apply the +2 rule with progression of challenges!

Due to the dysautonomia, patients are in sensory overload, and it is our job to look for ways to reduce the input - address sleep and circadian rhythm and daily routine. Be sure to include breathwork and mindfulness. Reassure patients and explain what you're going to assess and how that will possibly affect them. Explain the goal of assessment and management and set realistic patient-centred self-management strategies and goals. 

The question we ask ourselves should not be if this technique works, rather, if this technique is appropriate for this particular patient and this particular point in their rehab journey .