The Basics of Concussion Rehab

What is Concussion Rehabilitation?

What is a concussion?

To answer that question I think it is important to first understand what a concussion is not. A concussion is not a structural injury, meaning that it will not show up using any of our traditional imaging techniques (MRI and CT scan). If you or someone you know initially went to the ER after suffering a head injury and imaging was ordered, it was not to “rule in” a concussion, it was to “rule out” other, more serious pathology such as a brain bleed.

So if it is not a structural injury what is it?

Rather than impact causing the injury, rapid movement causes shearing forces that cause damage to parts of our neural cells called “axons.”
This disruption causes a change in ion concentration inside and outside the cell as well as a spike in glutamate, our body’s main excitatory neurotransmitter.
Initially, this change causes many cells to fire in what is called “spreading depolarization” and a lot of energy is released.
After this initial spreading depolarization which ends within a few minutes after injury, the body wants to return to normal, the problem with this is that it requires a lot of energy to pump ions back where they belong. One of the complications of the initial change in ion concentration is a lot of calcium rushes inside the cell. This is problematic because calcium is toxic to our mitochondria, the “powerhouse” of our cells that is responsible for producing the energy required to restore our ion balances back to normal.
We now have a high demand for energy but a low supply creating an “energy crisis” that lasts 7-10 days in adults and even longer in children and adolescents.
In the image below, we can see how long it normally takes for ion balances, chemical balances, and cerebral blood flow to return to normal after a concussion.
Blood flow to the brain decreases by about 40% with injury which is a great protective mechanism for our brain to mitigate the effects of a brain bleed if present; but since a concussion is not a structural injury, this decrease in blood flow may do more harm than good.

For all of these reasons, concussion is considered a "functional injury"

Giza, C. C., & Hovda, D. A. (2014). The new neurometabolic cascade of concussion. Neurosurgery, 75(suppl_4), S24-S33.

OK, so what do I do to make things get better?

Initially rest is OK. In the first day or two after your injury, take it easy, maybe take a day off of work or school and let your brain begin to recover. After that point, you should begin to do “symptom limited activity” meaning you can do normal day to day things like cleaning, light yard work, going for a walk etc. and see how you do. If you do well and have no symptoms, great! You can begin to increase your activity level each day. If it does provoke symptoms, that is also perfectly fine. Symptoms after a concussion are ok and are actually an important part of the rehab process. As long as your symptoms stay fairly mild (< 5/10) you are ok to continue with your activities; if you find that your symptoms are bothering you significantly, take a break and let things calm down.

People who gradually begin symptom limited activity early tend to have better outcomes than those who completely shut down and “stay in a dark room” for days and weeks waiting for their symptoms to completely go away before starting to resume their life.

When should I see a healthcare provider?

The best way to ensure that your symptoms do not become persistent is to get in with a provider early, within the first few days after initial injury. The longer you wait to begin targeting your impairments, the greater risk they have to become persistent. My recommendation is, take the little bit of time to be seen and get things under control early as opposed to waiting until things become persistent which makes the rehab process longer and more difficult.

I didn’t know about concussion rehab and I've had symptoms for a long time, now what?

Most patients will have symptom resolution within about 14 days. When symptoms persist much beyond this time it is called “post-concussion syndrome”, or “persistent concussion symptoms”, both abbreviated “PCS.” At this point it is very important that you undergo a thorough evaluation to tease out the factors that may be contributing to your injury and get you started on a program that will help your symptoms begin to resolve.

What does this evaluation look like?

There are different concussion “limiting profiles” that include:

• Vestibular
• Ocular Motor
• Cervical
• Exertion
• Cognitive/fatigue
• Anxiety/Mood
• Post-traumatic Migraine

(items in bold indicate items that can be primarily managed by a physical therapist, other items may require additional medical management)

Here are some questions you can ask yourself to determine potential contributing factors to your concussion symptoms.

Vestibular:

• Do quick movements make you dizzy, foggy, anxious?
• Do busy environments cause you to have a headache or feel foggy, dizzy, anxious, or tired?
• Do you become dizzy when looking up/down, turning head, walking down busy hallways?
• Do you get dizzy or nauseous while looking out the window of a car.

Ocular Motor:

• Do you feel frontal pressure in your head/behind your eyes with visual work?
• Do you have more trouble in math and/or science than other subjects?
• Do you have a hard time bringing objects into focus when looking up and down?
• Are you experiencing blurred or fuzzy vision while reading or difficulty reading?
• Have you had to change your preferred sitting location in class?

Cervical:

• Do you have neck pain?
• When you get your headache, where does it start?
• Are there certain neck movements or positions that will cause your headache?
• Do you have a history of neck injury or MVA?
• Was your head whipped around at the time of injury?

Exertion:

• Do your symptoms seem to increase with an increase in heart rate or activity level?
• Do you have a headache increase after walking up a few flights of stairs? - especially in the absence of other symptoms.

Cognitive/Fatigue:

• Does HA increase as the day progresses?
• Are you feeling more tired at the end of the day than normal?
• Are you more distracted at work/school than normal?
• Do you find yourself skipping lines while reading?

Anxiety/Mood:

• Do you spend a lot of time thinking about your injury and current symptoms?
• Are you having symptoms during downtime when you are alone?
• Are you having any difficulties falling asleep?
• How often do your parents ask you about your symptoms?

Migraine:

• Do you have a history of migraine headaches prior to injury?
• Do you have a headache in the morning after a poor night's sleep?
• Do you have dysregulated sleep?
• Have you noticed any visual changes before or during your headaches?
• Do you become sensitive to normal room light or noise during your headache?

You will be put through assessments targeted at each of the “limiting profiles” that may be contributing to your symptoms. This assessment may or may not be able to be completed in one session depending on the severity of your symptoms and how in depth of a dive your presentation warrants into each of the individual profiles.

What does treatment look like?

Treatment is established based on the findings on your initial examination.

Much of the treatment for concussion symptoms is what is called “habituation” which is the process of getting your brain accustomed to a new, higher level of stimulus than it was previously able to handle. Over time, your tolerance will increase and you will be able to perform higher level exercises and activities until you have returned back to normal.

How will I know when rehab is over?

In order to be cleared from physical therapy you will need to pass all basic vestibular, ocular, cervical, and balance testing without symptoms. You must also be able to tolerate high level physical activity involving head and eye movements without symptoms. This clearance test will take approximately 1 hour and consists of about 20-30 minutes of cardio activity followed by 30-40 minutes of interval and sport specific training designed to challenge the ability of the body to meet the need for increased blood flow to the brain during intense exercises while also challenging the vestibular/ocular motor system.

Reference Articles:

• Giza, C. C., & Hovda, D. A. (2014). The new neurometabolic cascade of concussion. Neurosurgery, 75(suppl_4), S24-S33.
• Kontos, A. P., Sufrinko, A., Sandel, N., Emami, K., & Collins, M. W. (2019). Sport-related concussion clinical profiles: clinical characteristics, targeted treatments, and preliminary evidence. Current sports medicine reports, 18(3), 82-92.
• Worts, P. R., Burkhart, S. O., & Kim, J. S. (2019). A physiologically based approach to prescribing exercise following a sport-related concussion. Sports medicine, 49(5), 683-706.