In the past few years concussions in sports has received a great deal of attention across all forms of media as people in the medical and sports worlds have begun to speak out about the long-term effects associated with concussions. The Centers for Disease Control estimates that 3.8 million concussions occur each year during sports activities. It is alarming statistics like this that have led to recent scientiﬁc research indicating the need for concussion identiﬁcation, early management, rehabilitation, and prevention.
WHAT IS A CONCUSSION? A concussion is a type of brain injury that can cause long-term brain damage and diminish normal brain functioning. The actual brain injury is caused by a blow to the head or the body causing the brain to rapidly move inside the skull. Concussions can occur from a direct bump or blow to the head or from an indirect cause such as whiplash, a fall, or when players collide. It is important to know that fewer than 10% of sports-related concussions result in a loss of consciousness2. That means that the athlete may have a concussion even if they did not lose consciousness. Remember all concussions are serious. The potential for concussions is greatest in those sports where collisions are common1. For males, football is the most common sport with concussion risk and for females it is soccer2. Concussions can occur, however, in any organized sport or recreational activity.
WHAT ARE THE SIGNS & SYMPTOMS? Signs and symptoms of a concussion may show up right away or they may not appear or be noticed until days or weeks after the injury. It is always important that if an athlete reports any of the below symptoms at any point after an injury, medical attention should be sought.
WHAT IF A CONCUSSION IS SUSPECTED? Athletes who experience any of the listed signs or symptoms after an injury should be taken out of play and seek immediate medical attention. Athletes should not return to play until permission is granted by a healthcare professional with experience in evaluating concussions. Concussions can be easy to miss by healthcare professionals who are not speciﬁ cally trained in concussion diagnosis. Most diagnostic imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT) scan, usually appear normal. To obtain a thorough evaluation of the injury and treatment plan when needed, multiple healthcare professionals should be included in the athlete’s care including a physician, neuropsychologist, and a vestibular physical therapist. Vestibular physical therapists can evaluate the extent of imbalance and can create customized treatments for dizziness and balance dysfunction associated with concussion. It is estimated that dizziness occurs in more than 55% of sports-related concussions3. Once the medical team has determined that the athlete has in fact sustained a concussion; the team should develop a treatment plan to manage any symptoms. The following are some common components of a treatment plan:
- Rest is the treatment of choice after determining that the athlete is not at risk for a brain hemorrhage (or brain bleed). The athlete should limit both physical activity and intense thought until post-concussive symptoms have cleared.
- Protection from additional injury is also very important to minimize the damage done to the brain. There is also evidence that the brain is more susceptible to further damage while it is healing from a concussion.
- Medication may be beneﬁcial in cases in which recovery is incomplete after a period of rest. When indicated, medications are typically prescribed to manage the concussion symptoms which may include headache, sleep disturbances, or mood changes.
- Neurocognitive assessment is typically performed by a neuropsychologist or physician and is helpful in determining the presence of a concussion and assessing the recovery after the injury.
- Balance Testing, usually performed by a physical therapist is also very helpful in determining the physical effects after a concussion and can be used to track recovery as well as appropriate timing for return to sport. Currently the best equipment available for this balance testing is the NeuroCom® SMART Equi-Test System which can evaluate changes in balance as well as changes in the brain’s ability to adapt to changing balance circumstances.
HOW CAN PHYSICAL THERAPY HELP? Physical therapists have recently been added to the medical team for concussion management. Physical therapists can evaluate and treat many problems related to concussion. Because no two concussions are the same the physical therapist will provide an individualized exercise and training plan to reduce the symptoms of a concussion including dizziness, headaches, and imbalance. This treatment plan may include vestibular rehabilitation, visual training, manual therapy, balance retraining, and aerobic exercise. The key to concussion rehabilitation is ﬁnding the right physical therapist who is speciﬁcally trained in the examination of an individual after a concussion and who has signiﬁcant experience in treating dizziness and balance. These therapists are typically referred to as vestibular physical therapists. You can search for a qualiﬁ ed physical therapist in your area at www.vestibular.org or www.balanceandmobility.com. Here are some general tips when you’re looking for a physical therapist:
- Get recommendations from friends or family or from other healthcare providers such as your physician.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in vestibular rehabilitation or concussion management.
- During your ﬁrst visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and tell them what makes your symptoms worse4.
Physical therapists in some locations can now also perform balance testing with the NeuroCom® SMART Equi-Test to provide baseline measurements prior to the sports season, which can later be compared to in the event of a concussion. This testing not only helps to quantify the severity of the balance problems after concussion, but it is also the best measure to indicate when it is safe for the athlete to return to play.
HOW TO PREVENT FUTURE CONCUSSIONS? It is clear that with participation in any sport, there will always be a risk of getting injured, but there are precautions that we can take to minimize the risk for concussions. It is important that athletes wear the appropriate protective equipment including helmets, padding, shin guards, and eye and mouth guards. Protective equipment should ﬁt properly, be well maintained, and be worn consistently and correctly. Athletes should also be taught safe playing techniques and encouraged to follow the rules of the game7.
Another key to concussion prevention is education regarding the health risks and long term effects of a concussion. In October 2012 the Academy of Pediatrics suggested that high school football players don’t take concussion symptoms seriously and would rather risk their health than lose valuable playing time on the ﬁeld5. The study found that only 38% of the student athletes surveyed worried about the long-term effects caused by a concussion. An NFL study released in 2012 showed that 6.1% of retired players above age 50 reported diagnoses of dementia, Alzheimer’s, and other memory related diseases, compared with 1.2% for the general male population in the United States6. This indicates a clear connection between early concussions and their associated long-term effects. Young athletes need to be aware of the potential health risks and long-term effects of concussions. Athletes should also be aware that continuing to play while recovering from a concussion places them at much greater risk for re-injury, permanent brain damage, and possibly even death. Remember “It is better to miss one game than the whole season.”7
Article written by Jennifer Feenstra, DPT
Jennifer Feenstra is a vestibular physical therapist at Element Physical Therapy in Missoula, Montana.
References: 1. Powell JW. Cerebral concussion: causes, effects, and risks in sports. Journal of Athletic Training 2001; 36(3):307-311. 2. Sports Concussion Institute. Concussion Facts. http://www. concussiontreatment.com/concussionfacts.html. Accessed February 27, 2013. 3. Pellman EJ, Powell JW, Viano DC, et. al. Concussion in professional football: epidemiological features of game injuries and review of the literature – part 3. Neurosurgery. 2004; 54(1):81-96. 4. Move Forward Guide: Physical Therapist’s Guide to Concussion. March 24, 2011. http://www.moveforwardpt.com/ symptomsconditionsdetail.aspx. Accessed February 25, 2013. 5. American Academy of Pediatrics. Many high school football players no concerned about concussions. October 22, 2012. http://www. aap.org/en-us/about-the-aap/aap-press-room/Pages/Many-HighSchool-Fotball-Players-Not-Concerned-About-Concussions.aspx. Accessed February 27, 2013. 6. Weir D, Jackson J, Sonnego A. University of Michigan Institute for Social Research September 10, 2009. National Football League Player Care Foundation: Study of Retired NFL Players. http://www.ns.umich. edu/Releases/2009/Sep09/FinalReport.pdf. Accessed February 27, 2013. 7. Centers for Disease Control and Prevention. Concussion in Sports. July 23, 2012. http://www.cdc.gov/concussion/sports/index. html. Accessed February 25, 2013.