Concussion and Post-Concussion Syndrome
Please book an assessment if you have had any trauma along your spine, to your neck and/or head. Symptoms vary and in some cases may be absent, but the central nervous system may still be sub-optimally functioning, which will be evident in the assessment. Baseline deficits, an action plan and more specific recommendations can only be made on a client-to-client basis as every case of concussion is unique, and requires an individualized treatment approach and plan. Generic concussion-related advice does not encompass the complexity of each individual case.
A concussion is classified as a mild traumatic brain injury (mTBI). Concussion occurs with a traumatic injury to the head, neck, or elsewhere in the body with biomechanical forces being transmitted to the skull. This can occur in sport (contact sports OR otherwise), motor vehicle accidents, falls, collisions etc. This impact results in shearing of the axons in the central nervous system referred to as diffuse axonal injury (DAI), or injury to the hardwiring of the central nervous system. Acceleration and deceleration forces are transmitted to the brain, which can cause the brain to collide with the inside of the skull in various directions (picture shaking a bowl of Jell-O back and forth!).
A concussion results in the shift in ionic balance at the cellular level and a decrease in cerebral blood flow following concussion. Ultimately, this results in an energy crisis – picture having to function at 100% of daily activity on minimal sleep for a prolonged period: not fun! This is how a patient who has sustained a concussion feels on a daily basis. The majority of initial concussion injuries resolve in approximately 10-14 days, though this may last longer in children and adolescents due to incomplete neurological development.
It should be noted that the acute clinical signs and symptoms of concussion represent a functional disturbance rather than a structural injury, thus concussion does not appear on standard diagnostic imaging. The consulting medical doctor may refer for an MRI or CT scan to rule out brain haemorrhage or bleeding, but will not use an image to diagnose an acute concussion.
Post-concussion syndrome (PCS) refers to the sequelae of signs and symptoms that occur after sustaining a concussion. These signs and symptoms can last months to years, in severe cases, if not addressed properly.
Signs and symptoms include but are not limited to:
- Fatigue / drowsiness
- Balance deficits
- Blurry/double vision
- Sensitivity to light
- Sensitivity to noise
- Sleep difficulties (too little, too much, difficulty falling/staying asleep)
- Difficulty concentrating
- Difficulty remembering
- Mental “fogginess”
- Emotional distress
- Whiplash symptoms (neck tenderness/stiffness)
- Postural deficits
- Autonomic nervous system dysfunction
- Digestive issues
- Changes in heart rate, blood pressure, respiration
- Endocrine imbalance
- Possibility of chronic inflammation
The severity of symptoms can depend on a variety of factors. Typically, concussions that involve loss of consciousness or amnesia (difficulty remembering events around the impact) result in more severe symptoms, but neither of these two factors are required to sustain a concussion. As well, a person who has sustained multiple concussions, and closer in frequency tends to display more severe symptoms. Once a concussion has been sustained, it typically requires progressively less force or impact to induce a second or third concussion. Repetitive concussions and trauma can lead to chronic traumatic encephalopathy (CTE), a form of neurodegeneration that results in a variety of behavioural, psychological and cognitive changes. Structural changes at the neurological level can be seen post-mortem in these individuals.
Second Impact Syndrome
Second Impact Syndrome (SIS) occurs when a child or adolescent (under age of 18) athlete returns to sport too soon after sustaining a concussion, and sustains a second impact. This results in brain haemorrhage and neurological death within 3-5 minutes of the second impact. A graduated return to play protocol, with recommendations from a trained healthcare practitioner, should be in place to avoid the risk of SIS.
What can you do?
1. Recognize signs and symptoms: refer to a healthcare practitioner with a concussion management background for assessment. Diagnosis is typically completed by a family or sports doctor, but may occur in the emergency room if the patient initially seeks hospital attention. A physiotherapist, chiropractor, or athletic therapist with concussion management training then carries out treatment. The lead practitioner may elicit the services of a massage therapist, osteopath, naturopath, or dietitian to assist with treatment, depending on the symptoms.
2. Limit activities that demand attention, concentration and visual energy: limiting screens (TV, cell phone, video and computer games) in the early stages will contribute to neurological recovery. As well as avoiding busy environments (including the stands or bench at a game!) is recommended in early stages.
3. Implement a proper rest strategy: regulating the sleep cycle is imperative to early recovery from a concussion. See a healthcare practitioner with concussion management training for further details regarding sleep recommendations.
4. Engage in light activity below symptom threshold: Activity and exercise recommendations should be made by a healthcare practitioner. Recent research from the University of Toronto has shown that earlier initiation of aerobic exercise is associated with a faster full return to sport, school or work. Activity level should NOT worsen symptoms during recovery.
What can your Healthcare Practitioner do?1. Educate the patient on implementation of sleep recommendations, when to begin activity, graduated return to play or work, academic accommodations for students, exercise recommendations, and many more.
2. Address whiplash related symptoms.
3. Retrain visual and vestibular deficits with a series of exercises or activities related to the patient’s specific deficits.
4. Address balance deficits.
5. Complete sport-specific activities for athletes prior to return to play.
6. Address autonomic system imbalance, body mapping, and coordination of the multiple body systems.
ImPACT: Immediate Post-Concussion Assessment and Cognitive Testing
What is ImPACT?
ImPACT, or Immediate Post-Concussion Assessment and Cognitive Testing, is a computerized test used in Toronto Physiotherapy at Ace Sports Clinic. It is an objective measurement tool used in the assessment and management of concussion and post-concussion syndrome (PCS). It is a scientifically validated and FDA-approved test that allows clinicians to track progress of neurocognitive symptoms throughout the management of head injuries. ImPACT should be accompanied by a full clinical evaluation of PCS symptoms.
What does ImPACT assess?ImPACT involves a variety of computer-based tests that assess domains such as visual and verbal memory, reaction time, and visual motor speed, all of which can be affected with PCS.
What does ImPACT involve?ImPACT can be completed as a Baseline test (pre-injury) or as a Post-Injury test. Baseline testing is done to determine values for the domains listed above prior to head injury and is highly recommended for athletes that play contact sport. Post-Injury test scores can be compared with the athlete or client’s own Baseline scores, and/or within population normative values (if Baseline data hasn’t been assessed). The computer test takes approximately 30-45 minutes to complete; however, may take longer depending on symptom severity with head injury.
What occurs after ImPACT?Your clinician will use the values from the ImPACT test to help guide treatment, and can compare values as a means of objectively measuring improvement by completing a second or third test throughout the course of recovery.
· Lawrence DW, Richards D, Comper P, Hutchison MG (2018) Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion. PLoS ONE 13(4): e0196062. https://doi.org/10.1371/journal.pone.0196062
· McCrory, P. et al (2016) Consensus Statement on Concussion in Sport—the 5th International Conference on Concussion in Sport, held in Berlin, October 2016. http://dx.doi.org/10.1136/ bjsports-2017-097699
· Shift Concussion Management