Beyond Rest: Physical Therapists and Concussion

Management
By Eric Ries | March 2017

These are—if you'll pardon the expression—heady times for the role of
physical therapists (PTs) in care management of people with
concussion. Research advances and work being done by PT clinicians
across the country have firmly established PTs' place at this table.
The University of Pittsburgh Medical Center (UPMC) is a global leader in
testing, treating, and researching sports-related concussions.
"Better and better data lends support to how PTs—as members of
multidisciplinary health care teams—consider, manage, and create
treatment pathways for concussion in optimal and efficient ways," says
Mucha, a board-certified clinical specialist in neurologic physical therapy.
"Some medical professionals still are of the opinion that there's no way
to treat concussion other than to rest the patient," Mucha comments,
"but there's been rapid evolution of evidence to the contrary."
As movement experts, physical therapists know the positive aspects of
physical activity and exercise,
The potential drawbacks are vestibular, cervical, ocular, and
posttraumatic migraine. There are also cognitive/fatigue and
anxiety/mood cosequences.
Exception Is the Rule
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As Mucha puts it, "concussion is new"—at least as an area of intensive
study.
It's only been in recent years that concussion has been taken seriously
as a brain injury for which people come to physical therapy.
Evidence of brain injury from repeated blows to the heads of
professional football players has sharply heightened media and public
interest in postconcussion syndrome, which the Mayo Clinic defines as
"a complex disorder in which various symptoms, such as headaches and
dizziness, last for weeks and sometimes months after the injury that
caused the concussion." However, an estimated 80% to 90% of
concussions resolve themselves within 7 to 10 days.  
"I wish we could eliminate the word ‘concussion,' because to some
people it still means, ‘So, you got your bell rung—you'll be fine,'" says
Lauren Ziaks, PT. "But when you get a concussive force surging through
your body, there's a shearing of axons inside your brain, with
corresponding areas of cell death. That," she emphasizes, "is a brain
injury."
Ziaks speaks from experience as well as clinical training.
Given that the brain is the body's most complex and least understood
organ, there's nothing cut-and-dried about concussion management.
"We try to make people understand that concussion isn't the same for
each individual," Mucha says. "Many different clinical profiles present
after concussion, and they all require different evaluations and
management approaches."
For that reason, Ziaks finds treating patients with concussion deeply
fulfilling but also quite challenging.
"Five percent of my patients with concussion track in predictable ways,
and it's all beautiful, but the other 95% have their own unique
presentations and issues," she says. "That means you have to be agile
as a PT. You have to be educated, and you have to be ready to refer out
to other health care providers when issues are beyond your scope of
practice, or when your patient would do better to see another PT with
greater expertise in a given area."
Schwartz says, "Concussion is not an event—it's a process."
A "Recoverable" Injury
A national survey of 2,012 Americans, 18 and older, conducted in April
2015, found that although roughly 9 of 10 respondents couldn't correctly
identify what concussion is, about the same number consider it a
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moderate to severe health concern, 32% of parents "live in fear" that
their child will sustain a concussion, and 1 in 4 parents forbid their
children to play some contact sports because of that fear.
Such forced inactivity is alarming, given that more than one-third of
American children or adolescents were overweight or obese in
2012. But, also, the misapprehension that concussion somehow is tragic
—41% of the survey respondents considered it a "living nightmare"—is
incorrect in the vast majority of cases.
Concussion is a very recoverable injury.
Mucha says, "We don't want to overdramatize concussion. We don't
want people reducing their physical activity for fear of it. What we do
want, as PTs, is to continue exploring ways to lessen postinjury
morbidity in people whose recoveries are longer."
The typical symptoms and presentations include headaches, dizziness,
sensitivity to light and sounds, mental fog, disturbed sleep, irritability,
and quick cognitive fatigue.
All PTs should be able to identify the red flags for patients with
concussion who have persistent symptoms beyond normal recovery.
And don't disregard anything your patient reports.
Ask questions: ‘What makes it feel better?' ‘What makes it feel worse?'
‘Where's the headache coming from?' ‘What's the pattern of it?
More research also is needed to address the "why" of concussion.
Cochrane's patients often ask him why they sustained a concussion after
what seemed like a fairly minor blow to the head. The current research
doesn't provide a good answer.
"Let's say you and I were hit in the head in the exact same place, with
the exact same force. I might get a concussion, but you might not. Why
is that?" he asks. "We don't yet know the underlying reasons. But that's
where the research is going."
Rylander poses another significant question that research presumably
will answer in the near or longer term: "What are the cumulative effects
of many, many subconcussive blows to the head?"
Future research, he says, "might lead not only to new recovery
strategies and intervention procedures, but to overall health policy and
even lifestyle changes."
All of which means "there's tremendous potential for minimizing the
effects of concussion in our patients and getting them back to their lives

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more quickly," Rylander enthusiastically observes. "Physical therapists
will be key members of the health care teams facilitating that."
I. Pre-reading:

What is concussion?
What causes it?
How is it treated?
What can continuous blows to the head eventually lead to?

Check the meaning of the following words:

drawback
dizziness
fatigue
mental fog
disturbed sleep

II. Now read the text.

III. Answer the following questions.

a) Which profile of patients does the text deal with?

b) What is the role of a PT in concussion management? How
should they approach the patient?
c) Draw the paralel between inactivity of children, fear of sports
injuries and concussion?
d) What are the numbers? What is the usual course of the
injury? How soon do patients recover?
e) What is te percentage of patients who recover in predictable
ways? What happens to the others?
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f) Based on which criteria does concussion classify as a brain
injury?