A concussion, also known as a mild traumatic brain injury (mTBI), is a very common injury that is experienced by hundreds of thousands of people each year. The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) recognize concussions as a national and international health crisis and have made recommendations for increased concussion awareness.
An estimated 2.5 million people sustain traumatic brain injuries in the United States alone each year, and a far greater number of people are affected worldwide. 75%-85% of those are mild traumatic brain injuries.
Per McCrory (2018), a traumatic brain injury is an injury induced by biomechanical forces. This may be caused by direct blow to head, or high-velocity forces transmitted through the head, typically resulting in rapid onset of short-lived impairment of neurological function that resolves spontaneously.
Overlapping networks within the brain control specific functions, which include balance, oculomotor function, cognitive function, and the integration of sensory information. As a result of a concussion, the information from the brain is slowed or is not able to be communicated, and this can lead to impaired function. Most of the time, symptoms of concussion can be seen immediately at the time of injury. Less commonly, there may be a delay in when symptoms start to appear. Clinical symptoms associated with concussion are a normal part of recovery and are divided into four subgroups: somatic/physical, cognitive, emotional, and sleep.
Symptoms generally improve in 80-90 percent of cases. Clinical symptoms of a concussion are nonspecific, and it is important to note that not all individuals are symptom-free in the absence of a concussion. This is critical to remember, as a patient/athlete may be able to return to full activity even in the presence of mild symptoms. We assess symptoms by utilizing a post-concussion symptom scale (PCSS) (Pardini 2004), (Lovell, 2006). The PCSS is 22-item, a self-reported scale that looks at symptom severity and the number of symptoms endorsed. Symptoms are rated on a 7-point Likert scale of 0 to 6, with 0 indicating the absence of a symptom and 6 indicating the most severe presence of a symptom. The score is based on a maximum of 132, indicating a severity level of 6 in all 22 symptoms.
Up to 20-30 percent of children experience persistent symptoms lasting months after injury (Babcock et al., 2013). There is a correlation between initial symptom count, severity, and predicted recovery time (Pardini 2004). Symptom severity is one of the strongest predictors of a protracted recovery. Females are also more likely to experience prolonged recovery and to report a greater number of concussive symptoms (McKeithan 2019).
If symptom severity is moderate to severe and/or the number of symptoms is greater than 10, it is recommended to refer the patient to a concussion specialist for management of care. Signs and symptoms that may indicate a more serious head injury warrant referral to an emergency care facility. These include decreasing or fluctuating level of consciousness, increasing confusion, increasing irritability, numbness in the arms or legs, worsening headache, pupils being unequal in size, symptoms worsening over time, repeated vomiting, slurred speech or inability to speak, inability to recognize people or places or seizures.
To properly assess a patient who has likely sustained a concussion, a multifaceted approach should be utilized. Individual tests are not sensitive for diagnosis and assessment of concussion. The consensus is that casting a wide net and looking at multiple systems increases the yield for identifying concussions (Broglio 2014 & 2015). Therefore, a comprehensive assessment battery should be performed to include all the areas of neural performance that are commonly impacted by concussion. When we look at neural performance, we need to address attention, sensory integration, motor reaction, and rapid adaptation. Sensory integration involves vision, auditory information, time estimation, and vestibular motion.
Typically, neuroimaging findings are normal in persons with concussion; thus, it is recommended that it be reserved for patients in whom severe skull or brain injury is suspected. New imaging techniques do not diagnose mTBI. “Advanced neuroimaging, fluid biomarkers and genetic testing are important research tools, but require further validation to determine their ultimate clinical utility in evaluation of … concussions” (McCrory 2018). At this time, identification of concussion remains a clinical diagnosis.
Return to Learn Accommodations
To determine the best plan of care for the concussed patient, the provider needs to identify the neural dysfunction as an aid to diagnosis. The recommended treatment strategy is to focus on person-centered goals, while characterizing injuries more specifically in order to provide targeted therapy and better prognostic information. Intervention earlier in the patient’s recovery process is more effective than a wait-and-see approach (Kontos 2020), resulting in faster recovery with fewer prolonged symptoms. Proper referrals are based on the results of the clinical assessments; matching treatment pathways to clinical trajectories may accelerate recovery (Collins 2014). A concussion plan of care may include referrals to behavioral health, orthopedic physical therapy, occupation therapy, speech language pathology, and vestibular rehabilitation.
In the past, strict rest for patients was recommended, but current research shows that it offered no added benefit (Thomas 2015) and that patients should be encouraged to become gradually and progressively more active after the first 24-48 hours. Prolonged periods of rest may be counterproductive to recovery. To keep individuals in a dark room and/or totally isolate them can have negative impact on their mood regulation, increasing depression and anxiety/nocebo effect, and can correlate to physical deconditioning (Silverberg 2013 & 2020). Prolonged rest is NOT the preferred treatment after mTBI (Chan 2018). Early return to moderate activities may help reduce the risk of post-concussion symptoms and may decrease symptom duration (Silverberg 2013).
Comprehensive therapy in mTBI engages the patient in active rehabilitation, decreasing the risk of developing secondary conditions. Physical therapists can assist individuals with vestibular dysfunction or other balance issues and can guide return to activity/play while minimizing symptoms. Occupational therapists can provide interventions for vision deficits following mild traumatic brain injury” (Simpson-Jones 2019) and assist with return to driving. Driving must be addressed after a concussion since it a complex task we complete on a regular basis. It requires a constant coordination of visual, cognitive, and motor skills to safely drive within a constantly changing environment (Barrash 2010). “Speech language pathologists are critical members of the rehabilitation team working with children with mTBI to assist with return to learn” (Brown 2019) and can work with adults to facilitate return to work. There are instances where neuropsychology may be of benefit to identify barriers to recovery. They can assist with return to work/learn accommodations, sleep hygiene, and formal testing, when needed.
Return to work/learn and return to play/activity timelines should occur gradually, progressing to each step based on symptoms. It is acceptable for symptoms to increase but in moderation. When working on pacing, progression, and prioritizing tasks, it is important to remember to take breaks. If symptoms increase, allow them to return to baseline levels before attempting to continue with the task or start a new task. (see tables 1 & 2)
What can interfere with recovery?
On average, uncomplicated recovery takes 22 days (Elbin, 2016). Premorbid conditions, such as history of complicated concussion recovery, headaches, family history of migraines, history of depression, anxiety, learning disability, or ADD/ADHD are primary risk factors for a longer recovery. A protracted recovery is defined as >21 days to return to learn (RTL) and return to play (RTP).
Factors that may slow down or interfere with recovery include alcohol use, illicit drug use, and use of certain medications, specifically the medication class of benzodiazepines (Valium, Xanax, Ativan, Klonopin), as this can slow healing after head injury. If you are on a medication in this class chronically, make sure to discuss with your doctor. If not, avoid these medications as you are healing.
Other factors that can limit healing are not getting enough rest, poor quality sleep, and increased psychosocial stressors, including ongoing legal or insurance issues related to the injury. A common cause of stress after a concussion is focusing on symptoms, which can lead to symptom exacerbation. Instead of focusing on symptoms, the patient should focus on being as active as possible, while minimizing symptom increase, thus aiding in recovery.
While most concussions heal well, in many cases it is helpful to be evaluated by a concussion specialist. Concussion specialists are most often physicians or neuropsychologists with specialized knowledge and treatment of concussions. A few websites that provide more information on concussions are listed below. If you have any questions during your healing process, it is always best to discuss them with your physician www.cdc.gov/headsup, www.shepherd.org/concussion, www.brainline.org