Concussion rehab involves managing symptoms through cognitive behavioral therapy, aerobic exercise, and vestibular therapy. Imaging like CT and MRI are usually normal following a concussion. Symptoms include cognitive deficits, fatigue, sleep issues, headaches and dizziness. Risk factors for prolonged symptoms include previous concussions, younger age, and mood disorders. Treatment progresses from rest to light exercise to sport-specific drills to full practice per graduated return to play guidelines.

1. Concussion Rehab
Cristina Wingerter

2. Concussion
● form of mild Traumatic Brain Injury (TBI)
● 1.6 to 3.8 million sports-related concussions per year in the US(Langlois, 2006 )
● cognitive and perceptual changes after a blow to the head (Kasper, 2015)
● often sudden deceleration of head while hitting a stationary object
● A-P displacement of brain inside skull

3. Imaging
CT and MRI usually clear (i.e. no structural changes)
● CT : only detects hemorrhage and edema
● MRI: can detect small contusions, hemorrhages
● no current technology able to individually diagnose or establish safe return to
activity

4. Grade
Grade 1: sx last for less <15 min. No LOC
Grade 2: sx last >15 min. No LOC
Grade 3: LOC (even for a few seconds)

6. Symptoms-PCS
Post-Concussion Syndrome (PCS)
-persistent syndrome beyond accepted
timeframe (most sources say 3 months)
(Carroll, 2004)
DSM IV definition:
1) cognitive deficits in attention/memory
2) and at least three of the following:
a) fatigue
b) sleep disturbance
c) headaches
d) dizziness
e) irritability
f) apathy
g) personality change

7. Predictors
*female sex
*hx of concussions
*younger age (older teenager, young adult)
*hx cognitive dysfunction
*affective disorders (i.e. anxiety and depression)
*length of posttraumatic amnesia
*(severity is not a contributing factor to development of PCS)

8. Differential Dx
*depression
*somatization
*chronic fatigue
*chronic pain
*cervical injury
*vestibular dysfunction
*visual dysfunction

9. Treatment
Acute
- rest **
PCS
- education (MD)
- cognitive behavioral therapy (neuropsychologist)
- aerobic exercise therapy and vestibular therapy (PT)

10. PT involvement
Acute
*on-field evaluation (sports and military)
Sub-Acute:
*balance/vestibular/neurologic screen
Rehabilitation:
*balance/vestibular therapy
*management of coexisting cervicogenic issue related to headaches/dizziness
*return to exertion

11. Exam: History
*description of mechanism of injury
*force of head trauma
*hx of concussions, mechanism, sx, duration, amnesia
*hx of migraine, depression, anxiety, ADD/ADHD
-TBI can exacerbate these
*medications: most commonly prescribed antidepressants

12. Exam: Measures
Symptoms
-post-concussion symptom scale (Lovell 2006)
-post-concussion symptom inventory (Gioia 2008)
Problem: underreporting common (McCrea, 2004)
Cognition
-neurocognitive testing (good if have baseline, not recommended stand alone)

14. Clinical Findings
Vestibular
-dizziness 32.5% at 5 years in PCS (Kontos, 2012)
-causes: BPPV, Labyrinthine concussion, post traumatic migraine, brain stem
concussion
-assessing: (1) head thrust test
(2) Clinical dynamic visual acuity test
(3) head shake nystagmus test

15. Clinical Findings
Abnormal Postural Control
-common acutely and subacutely (Kontos 2012)
- related to abnormalities in sensory organization
-ability to utilize and process vestibular information needed for postural control
affected (Peterson, 2003)
Testing: balance testing, gait assessment (dynamic gait index)
- appears to resolve more quickly than other symptoms following concussion
(Catena 2011)

16. Exertion
-student athletes who engaged in high levels of activity in the weeks following
concussion had increased symptoms, worsened neurocognitive data and significantly
longer recovery time (Majerske et al. 2008)
Neurometabolic Cascade:
increasing energy demand and decreased blood supply→ metabolic crisis

17. Exertional Rehabilitation

18. Exercise Pros
Prolonged Rest:
-deconditioning
-fatigue
-reactive depression
-exercise positive effects on mental health
-exercise promotes neuroplasticity and enhances neuroprotective properties
(Griesbach et al, 2008)

19. Exercise Cons
- animal studies: within 1st week impair cognitive performance but after 14-21
improved cognitive performance (Griesbach GS 2004)

21. PT Management
- systematic monitoring throughout session of HA and fogginess (mindful of
migraine provocation)
- proceed at slower rate than with peripheral injuries
- initial stages: exertional exercise may be contraindicated
- vestibular rehab, ocular motor training, management of cervicogenic issues, treat
BBPV with Canalith repositioning, sensory integration exercises, and balance
training

22. Graduated Return to Play Guidelines
Rehabilitation Stage Functional Exercise Objective
No activity, complete rest sx limited physical and cognitive rest Recovery
Light aerobic exercise Walking, swimming, cycling, low intensity
(below 70% HR). No RT
Increase HR
Sport specific exercise skating drills in hockey, running drills in
soccer. no head impact
Add movement
Non-contact training drills Progression to more complex training drills Exercise, coordination and cognitive load
Full contact practice Following medical clearance participate in
normal training activities
Restore confidence and assess functional
skills by coaching staff
Game play Normal game play

23. Return to Play
Athletes can gradually return to play if:
1) completely asymptomatic presentation
(during rest and activity)
2) normal neurocognitive evaluation
3) off medications (that mask sx)
Guidelines from International Conferences
on Concussion in Sports: Vienna 2001

24. Citations
1. The epidemiology and impact of traumatic brain injury: a brief overview.Langlois JA, Rutland-Brown W, Wald MMJ Head Trauma Rehabil.
2006 Sep-Oct; 21(5):375-8
2. Ropper AH. Concussion and Other Traumatic Brain Injuries. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds.
Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015.http://accessmedicine.mhmedical.com.ezproxy.
simmons.edu:2048/content.aspx?bookid=1130&Sectionid=79756215. Accessed October 12, 2015
3. Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.Carroll LJ,
Cassidy JD, Peloso PM, Borg J, von Holst H, Holm L, Paniak C, Pépin M, WHO Collaborating Centre Task Force on Mild Traumatic Brain
InjuryJ Rehabil Med. 2004 Feb; (43 Suppl):84-105.
4. Coel RA, Hoang QB, Vidal A. Sports Medicine. In: Hay WW, Jr., Levin MJ, Deterding RR, Abzug MJ. eds. CURRENT Diagnosis &
Treatment: Pediatrics, 22e. New York, NY: McGraw-Hill; 2013.http://accessmedicine.mhmedical.com.ezproxy.simmons.edu:
2048/content.aspx?bookid=1016&Sectionid=61602855. Accessed October 12, 2015.
5. Leddy, J. Sandu, H. Sodhi, V. Rehabilitation of Concussion and Post-Concussion syndrom. Sports Health. 2012. 4(2):147-154.